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Carl  Beck 


Is  ADpendicitis  a  Surgical  Disease? 


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IS  APPENDICITIS 
A  SURGICAL   DISEASE? 


CARL  BECK,  M.D., 

HEW    YORK. 


BEPBINTED  FROM  THB 

"Neto  York  iWetJfcal  Journal 

for  November,  IS,  19,  and  26, 
and  December  10,  1898. 


Reprinted  from  the  New  Tork  Medical  Journal 
for  November  12^  19^  and  ^6,  and  Becernber  10^  1898. 


IS   APPENDICITIS   A   SUKGICAL   DISEASE? 
By   carl    beck,   M.  D., 

NEW  TORK. 

Appendicitis  is  an  inflammation  of  the  vermiform 
process  due  to  infection.  Is  such  infection  due  to  the 
invasion  of  a  specific  bacterium,  or  to  the  cooperation  of 
two  or  more  different  species?  The  question  is  not  yet 
settled;  but  the  majority  of  observations  point  toward 
the  ubiquitous  Bacterium  coli  commune  as  playing  the 
main  part  in  the  infection.  Other  species  are  found 
in  the  colon :  the  Streptococcus  lanceolatus,  the  Bacillus 
pyogenes^  the  different  varieties  of  proteus,  the  Bacillus 
suhtilis,  and  sometimes  staphylococci.  Streptococci  are 
found  more  frequently ;,  the  liquefying  as  well  as  the 
non-liquefying  type.  Eegarding  the  repute  of  the 
streptococcus,  it  is  no  more  than  natural  that  there  is  an 
inclination  to  hold  it  responsible  to  a  great  extent  for 
originating  appendicitis,  especially  in  its  highly  virulent 
forms. 

Welch  maintains  that  it  is  the  combined  influence  of 
the  colon  bacterium  and  streptococcus  which  causes 
appendicitis,  and  that  the  failure  to  discover  strepto- 
cocci on  the  artificial  soil  does  not  necessarily  prove 

COPTRIGUT,    1898.   BY    D.^'APPLETON   AND   COMPANT. 


2  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

their  absence.  The  colonies  of  the  Bacterium  coli  com- 
mune grow  so  rapidly,  and  are  so  overshadowed,  that 
they  are  overlooked.  So  it  might  be  that  from  the  stand- 
point of  the  companionship  of  two  different  types  of 
bacteria  the  higher  toxic  potency  of  the  various  types  of 
appendicitis  could  be  explained. 

Whether  each  of  these  bacterial  species  alone  will 
originate  appendicitis,  or  whether  two  or  more  associ- 
ated species  together  are  required,  has  as  yet  not  been 
practically  demonstrated.  Theoretically,  there  seems  to 
be  no  reason  why  each  pathogenic  species  alone  could  not 
produce  the  infection.  It  is  a  well-known  fact  that  the 
virulence  of  the  Bacterium  coli  coinmune  sometimes 
may  become  enormous.  According  to  Lesage  and  Ma- 
caigne  {Archives  de  med.  experiment,  et  d'anatom. 
pathol.,  1892),  it  produces  but  insignificant  effects  if 
grown  on  a  healthy  surface,  but  causes  the  most  intense 
reaction  when  isolated  from  tissues  which  have  under- 
gone pathological  changes.  Thus  its  virulence  is  the 
higher  as  the  disease  is  graver  in  which  this  bacterium 
is  found.  The  fact  that  cultures  taken  from  a  case  of 
cholera  showed  a  high  virulence,  while  those  taken  from 
a  pus  focus  were  weak,  is  in  entire  accord  with  this 
theory.  It  will  be  reserved  for  the  cooperation  of  sur- 
geons possessing  bacteriological  knowledge  to  appreciate 
these  different  theories  so  far  that  practical  results  can 
be  deduced  from  them. 

One  of  the  greatest  difficulties  in  estimating  the 
toxic  dignity  of  the  Bacterium  coli  commune  is  caused 
by  its  not  representing  a  distinct  uniform  species,  but 
a  whole  series  of  different  subspecies,  which,  while  alike 
in  many  respects,  still  show  a  few  small  but  neverthe- 
less well-marked  diversities.     The  great  difficulties  of 


IS   APPENDICITIb   A   SURGICAL   DISEASE?  3 

differentiation  may  best  be  illustrated  by  the  fact  that 
Park  goes  even  as  far  as  to  maintain  that  the  Bacterium 
coli  commune  should  probably  be  identical  with  the 
Bacillus  neapolitanus  Esclierich,  the  Bacillus  foetidus 
Passet,  the  Bacillus  aerogenes,  and  a  variety  of  other 
forms. 

It  is  well  known  that  the  much-debated  Bacterium 
coli  commune  is  the  most  common  inhabitant  of  the  in- 
testines of  man,  as  well  as  of  many  animals,  such  as  the 
dog,  cat,  goat,  hog,  cow,  mouse,  rabbit,  etc.  Thorough 
examination  reveals  the  presence  of  this  ubiquitous  bac- 
terium in  the  oral  cavity  of  almost  every  healthy  person. 
As  long  as  the  mucous  membrane  of  the  intestine  i? 
normal,  it  causes  no  disturbance  whatsoever.  But  as  soon 
as  there  is  the  slightest  erosion  of  the  epithelium,  it 
will  readily  be  absorbed.  This  will  happen  so  much  the 
easier  when  there  are  other  disturbances  in  the  intes- 
tina.l  tract. 

According  to  Gilbert,  Eoger,  and  others,  it  forms 
very  virulent  tissue-change  products,  which  are  probably 
rendered  innocuous  by  the  liver,  or  more  so  by  the  bile. 
There  is  no  better  proof  for  the  fact  that  disturbances 
of  circulation  offer  a  most  provoking  moment  for  infec- 
tion than  the  experience  that  in  hernial  incarceration 
it  is  found,  having  advanced  as  far  a*s  to  the  serosa. 
That  abrasions  of  the  mucous  membrane  are  the  avenue 
for  the  invasion  is  evidenced  also  by  the  frequent  pres- 
ence of  the  Bacterium  coli  commune  in  dysentery,  ty- 
phoid fever,  and  cholera.  And  there  is  hardly  any  other 
organ  of  the  human  body  where  the  chances  of  a  circu- 
latory disturbance  and  of  the  abrasion  of  the  mucous 
membrane  are  offered  with  such  frequency  as  in  the 
vermiform  process.    We  need  only  to  consider  its  situa- 


4  IS  APPENDICITIS   A   SURGICAL   DISEASE? 

tion  above  the  ileo-psoas,  a  muscle  so  extensively  used, 
the  length  of  its  channel,  which  is  in  no  proportion  to  its 
small  calibre;  furthermore,  the  shortness  of  its  mesen- 
teriolum,  and  last,  but  not  least,  its  low  power  of  ex- 
pulsion. Eemembering  the  scantiness  of  its  muscular 
tissue — there  is  but  a  small  circular  layer — this  lack  of 
expelling  power  can  be  well  appreciated  (Fig.  1). 

j^<^?^.^ijK^^Vv.:i-:;":-  ->"^V>f:--     Gland. 
_^Si^35'^v^»r^§r^«5-^^^5^'^    Submucosa. 

^"^  ^%  <^<^    Circular,  1  ,, 

-^  .         -       _^^Loiisifudiiial.  j      '^''''^■ 
~  zi:_-rgn^  Serosa. 
Fig.  1.— Section  through  normal  appendicular  wall. 

A  certain  amount  of  circulation,  however,  in  the 
vermiform  process  must  be  possible.  I  have  made  it  a 
rule  for  several  years  (see  Journal  of  the  American 
Medical  Association,  December  28,  1895)  to  examine 
the  vermiform  process  in  each  case  of  abdominal  section. 
I  have  repeatedly  found  masses  of  moderate  hardness, 
probably  faecal  concretions,  in  individuals  who  had  never 
up  to  that  time  and  have  not  since  then  shown  any 
symptoms  of  disease  of  this  organ.  Slight  pressure  suf- 
ficed to  void  such  contents  into  the  caecum. 

Appreciating  the  fact  that  in  the  majority  of  cases 
the  vermiform  appendix  reaches  as  far  as  the  true 
pelvis,  it  can  easily  be  explained  how  kinks  and  twists  are 
caused,  which  are  apt  to  prevent  mechanically  the  evacua- 
tion of  the  appendicular  contents  into  the  caecum.  The 
limits  of  this  work  forbid  my  entering  into  the  various 
occasional  causes  more  particularly.     I  shall  only  re- 


I 


IS  APPENDICITIS  A   SURGICAL   DISEASE?  5 

mark  that,  regarding  my  own  experience  in  two  hun- 
dred and  seven  cases  of  appendicitis,  I  feel  justified  in 
emphasizing  the  rarity  of  real  foreign  bodies.  Only 
twice  have  I  found  real  foreign  bodies  in  the  appendix 
— once  the  traditional  grapeseed,  and 
another  time  a  few  cumin  seeds.  Fsecal 
concretions  are  frequently  found  —  I 
have  seen  them  forty-two  times — almost 
always  in  the  gangrenous  form. 

There  is  another  Eetiological  factor  „    ^     , 

°  Fig.  2. — Faecal  con- 

the  pathological  significance  of  which        cretion  from  a 
has,  so  far  as  mv  knowledge  goes,  as  vet        gangrenous   ap- 

'  "  00;'.  pendix. 

not    been    studied — namely,    the    right 
floating  kidney  pressing  the  appendix,  if  directed  back- 
ward toward  the  ileum. 

In  the  case  of  two  men,  one  being  thirty-three  and 
the  other  nineteen  years  of  age,  slight  pain  existed  for 
years,  the  intensity  of  which  increased  gradually.  In  both 
cases  it  was  located  partially  in  the  lumbar  and  hip-joint 
region,  and  partially  in  the  right  iliac  fossa,  so  that 
lumbago  as  well  as  coprostasis  was  repeatedly  diagnos- 
ticated. In  the  case  of  the  nineteen-year-old  patient 
even  coxitis  had  been  thought  of,  because  the  right  leg 
appeared  to  be  slightly  shortened.  In  both  cases  a  skia- 
gram had  been  taken,  which  illustrated  the  integrity  of 
the  bones.  Having  been  able  to  palpate  a  slight  resist- 
ance in  the  depth  of  the  iliac  fossa,  I  thought  of  chronic 
appendicitis,  and  opened  the  abdomen.  In  both  cases  a 
movable  kidney  was  discovered,  which  reached  down 
into  the  fossa,  pressing  the  appendix  against  the  ilium 
at  each  inspiration.  After  their  removal,  both  appen- 
dices, which  appeared  normal  on  the  outside,  showed 
strictures  and  contained  a  small  quantity  of  discolored 


6  IS  APPENDICITIS  A  SURGICAL   DISEASE  V 

and  decomposed  faeces.  Nephropexy  was  performed  at 
the  same  time  and  up  to  date,  fifteen  and  ten  months 
after  the  operation,  no  pain  was  noticed  by  either  of  the 
two  patients. 

In  the  case  of  a  lady,  thirty  years  of  age,  on  whom  I 
operated  in  the  second  attack  I  found  the  appendix 
buried  by  the  side  of  the  caecum  in  such  a  manner  that 
at  first  sight  there  seemed  to  be  no  appendix  at  all.  It 
was  only  after  some  search  that  its  structure  could  be 
identified,  for  it  had  almost  become  an  integral  part  of 
the  caecum.  Close  examination  revealed  a  deep-seated 
kidney  pressing  the  caecum  down  against  the  ilium.  The 
appendix,  which  was  directed  backward,  had  been 
pressed  against  the  ilium  so  that  it  had  become  flattened, 
and  at  the  time  of  the  first  attack  the  serous  surfaces  of 
the  appendix  and  csecum  were  fused  together,  the  appen- 
dix being  imbedded  in  a  groovelike  depression  on  the 
caecum.  By  careful  dissection  with  a  grooved  director  it 
was  enucleated.  At  its  tip  there  was  a  small  perforation 
containing  thick,  yellow  pus.  It  was  removed,  the 
stump  was  tied,  and  the  wound  was  treated  by  the  open 
method.  The  patient  recovered.  In  this  case  there  had 
been  digestive  disturbances  for  years,  and  at  one  time 
cholelithiasis  had  been  suspected. 

Edebohls,  to  whom  we  are  so  very  much  indebted 
for  the  discovery  of  the  means  of  palpating  the  appen- 
dix, mentions  the  frequent  occurrence  of  appendicitis 
in  connection  with  floating  kidney  in  general,  attribut- 
ing the  pathological  change  of  the  appendix  to  the  dislo- 
cation of  the  duodenum  and  pancreas  and  compression 
of  the  superior  mesenteric  vessels  between  the  head  of 
the  pancreas  and  the  bodies  of  the  spinal  vertebrse.  But 
it  seems  to  me  that  the  deeply  situated  movable  kidney 


IS  APPENDICITIS  A   SUEGICAL   DISEASE?  7 

exerts  its  pathogenic  influence  directly  upon  the  ap- 
pendix. 

Thus  disturbances  of  circulation  may  be  produced 
which,  while  in  themselves  of  a  slight  nature,  are  still 
sufficient  to  cause  swelling  and  obstruction,  even  after 
the  original  cause,  the  twist,  the  kink,  or  the  compres- 
sion have  again  ceased  to  exist.  The  swelling  of  t]ie 
mucous  membrane  is  usually  at  the  spot  where  its  circu- 
lar duplicatures  are  found,  as,  for  instance,  above  Ger- 
lach's  valve,  which  corresponds  to  the  ostium  of  the 
appendix  at  the  caecum.  Naturally,  the  appendicular 
secretion  is  apt  to  be  retained  below  there.  The  further 
consequences  are  its  decomposition  and  irritation.  The 
presence  of  faecal  concretion  may  represent  an  additional 
getiological  factor  as  a  mechanical  insult.  As  alluded 
to,  the  contractility  of  the  appendix  is  slight  under  ordi- 
nary conditions.  How  much  more  its  contractility  will 
be  impaired,  if  there  be  a  swelling,  and  a  swelling  means 
the  presence  of  oedema,  can  easily  be  imagined. 

And,  moreover,  how  fruitful  a  field  for  the  develop- 
ment of  bacteria  is  this  hollow  organ,  which  resembles  a 
caecum  in  miniature.  Its  comparison  with  the  tonsil  in 
view  of  its  glandular  richness,  unequaled  by  any  other 
portion  of  the  intestinal  tract,  is  quite  obvious.  To 
appreciate  the  analogy,  there  is  no  nee|i  to  go  as  far  as 
Golouboff  {Berliner  Jclinische  Wochenschrift,  1897, 
No.  5)  did,  who  regards  appendicitis  as  of  epidemic 
origin,  just  like  a  tonsillar  angina.  But  by  consider- 
ing that  the  appendix  is  in  itself  a  large  blind  alley, 
while  the  tonsil  is  a  conglomeration  of  many  small  blind 
alleys,  by  further  realizing  that  both  organs  touch  the 
two  body  cavities  abounding  more  with  bacteria  than  any 
other,  the  comparison  can  not  be  helped.     There  are  a 


S  IS  APPENDICITIS   A    SURGKJAL   DISEASE  y 

few  other  factors  j^ointing  to  the  similarity — namely, 
the  well-pronovmced  predilection  for  an  early  age,  espe- 
cially in  the  male,  and  the  early  manifestation  of  the 
inefficiency  of  their  expulsive  power  against  bacteria 
invasion,  according  to  their  anatomical  structures. 

For  a  better  understanding,  the  anatomical  relations, 


Organizing  fibrin. 


Mucous  membrane  with 
glandular  fragments. 


Submucosa. 


Circular. 


Longitudinal. 


Serosa. 


Fibres 
of  nius- 
cularis. 


Fig.  3. — Appendix  wall  in  simple  appendicitis. 


as  shown  in  Fig.  1,  should  be  recalled.  There  we  have 
to  deal  with  a  mucous  membrane  containing  little  epi- 
thelium and  a  glandular  and  submucous  layer,  the  lat- 
ter showing  traces  of  a  muscularis  mucosa.  Then  fol- 
low the  circular  and  longitudinal  stratum,  which  are 
protected  by  the  subserosa  and  serosa. 


IS  APPENDICITIS   A   SURGICAL   DISEASE?  9 

There  can  be  no  doubt  that  once  in  a  while  the 
irritating  contents  force  their  escape  into  the  cascum, 
and  it  is  then  that  from  a  clinical  standpoint  the  diag- 
nosis "  colic  of  the  appendix  "  will  be  made.  But  in  far 
the  greater  majority  of  cases  the  invasion  of  bacteria 
into  the  submucosa  means  the  breach  being  shot,  and 
then  there  is  no  further  halt  to  the  progression  of  the 
infection. 

The  muscularis  rapidly  being  permeated,  the  sub- 
serosa  and  serosa  are  attacked  soon.  Accordingly  the 
wall  of  the  appendix  becomes  thickened.  The  contents 
of  the  channel  become  mucopurulent.  This  anatomical 
condition  corresponds  to  what  from  a  clinical  standpoint 
is  usually  called  "  appendicitis  simplex." 

Microscopically  the  vessels  of  mucosa  and  submucosa 
appear  to  be  dilated  and  filled  with  red  blood-corpuscles. 
In  the  tubular  glands  there  is  an  accumulation  of  large 
cells  and  in  the  interstitial  tissues  there  is  an  infiltration 
of  embryonic  cells.  The  infiltration  with  small  cells 
proceeds  to  the  muscular  stratum  and  forces  its  fibres 
asunder,  thereby  causing  complete  paresis  of  the  muscu- 
laris. Now  the  subserosa  and  serosa  participate,  too, 
showing  considerable  multiplication  of  their  endothelial 
cells.  There  also  fibrinous  exudate  may  organize,  lay- 
ing the  foundation  for  partial  obliteration.  The  mus- 
cular tissue,  originally  so  scanty,  may  also  participate 
in  the  proliferation  and  hypertrophy   (Fig.  3). 

In  this  stage  resolution  takes  place  frequently — that 
is  to  say,  the  acute  process  subsides.  But,  according  to 
my  mind,  restitution  to  perfect  integrity  seldom  occurs. 
Sometimes  the  serosa  may  remain  intact,  but  in  most 
cases  it  will  become  adherent  to  the  adjoining  intes- 
tine, or  to  the  omentum,  or  to  the  abdominal  wall. 


10  IS   APPENDICITIS   A    SURGICAL   DISEASE  V 

The  mucosa  may,  except  at  a  few  cicatricial  points, 
the  sequelce  of  erosions,  appear  to  be  normal.  But  these 
scars  are  the  originators  of  strictures  (Fig.  4),  which 
cause  stagnation,  and  stagnation  again  may  cause  dila- 
tation on  other  points.  Thick  mucous  plugs,  tightly 
crammed  in,  and  organizing  fibrinous  exudates,  ob- 
structing the  lumen,  are  then  found  there  (Fig.  3). 
The  submucosa  and  mucosa  become  thickened  and  hyper- 
trophic, thus  enlarging  the  dimensions  of  the  whole 
appendix. 

Sometimes  there  results  a  progressive  tendency  to 
obliteration.  This  has  been  described  most  pictorially 
by  N.  Senn  as  appendicitis  obliterans.* 

It  goes  without  saying  that  all  these  conditions  must 
necessarily  provoke  recurrence  of  an  inflammatory  pro- 
cess sooner  or  later.  It  is  only  when  total  shrinking 
of  the  appendix  takes  place,  so  that  it  is  degraded  to  a 
simple,  bandlike,  functionless  appendage,  that  such  re- 
currence will  fail  to  set  in  again.  Thus  the  spontaneous 
cures  are  explained. 

In  periappendicitis  there  is  an  adhesive  peritonitis, 
combined  with  the  formation  of  fibrino-plastic  exuda- 
tion. There  a  resolution  may  take  place  in  the  same 
way  as  described  in  simple  appendicitis — namely,  the 
exudation  may  be  absorbed  and  the  acute  inflammatory 
symptoms  subside.  The  appendix  of  course  remains  in 
the  same  condition  as  if  there  had  been  an  appendicitis 
simplex  which  had  advanced  as  far  as  to  .the  serosa,  plus 
the  adhesion  of  its  serous  coat  to  the  neighborhood,  in 
which  it  sometimes  appears  like  a  mummy  baked  in  lava. 
It  does  not  need  urging  that  under  such  circumstances 
recurrence  of  inflammation  is  provoked  to  a  higher  de- 
*  Journal  of  the  American  Medical  Association,  March  24,  1894. 


IS   APPENDICITIS  A   SURGICAL   DISEASE' 


11 


gree  than  in  simple  appendicitis,  mecliauifal  causes  now 
also  being  added. 

But  very  frequently  resolution  does  not  take  place 
at  all  and  the  iutlannnatory  process 
proceeds    further.       This    can    take 
place  in  different  ways : 

The  inflaniniation  may  encroach 
upon  the  tissues  situated  nearest  to 
the  serosa,  and  the  exudation,  origi- 
nally having  been  of  a  serous  charac- 
ter, becomes  purulent.  It  may  safely 
be  assumed,  however,  that  the  exuda- 
tion, which  microscopically  appears 
to  be  of  a  serous  character,  contains 
pyogenic  bacteria  a  priori,  the  same 
as  in  serous  pleuritic  effusion,  which 
"  turns  over  into  pyothorax  "  {'peri- 
appendicular abscess) . 

Or,  the  inflammation  reaches  the 
peritonaeum  by  way  of  the  lymph  ves- 
sels as  a  true  lymphangeitis.  I  used  to 
term  this  variety,  in  proportion  to  its 
propagation,  either  circumscribed  or 
progressive  phlegmonous  appendicitis. 

Or,  the  secretion  of  the  appendix 
becomes  purulent  {pyappendix) . 
Then  in  the  vast  majority  of  cases 
perforation  takes  place  under  suc- 
cessive distention  of  the  walls  and 
pressure  necrosis.  The  perforated 
area  may  at  first  not  be  larger  than  the 
head  of  a  pin  and  may  enlarge  gradually.  Accordingly 
the  pus  may  enter  the  peritoneal  cavity  slowly  or  rapidly. 


Fig.  4. — Long  strictured 
appendix  removed  in 
chronic  appendicitis. 


12  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

Naturally,  the  peritoneal  area  adjoining  the  nearest 
perforated  spot  is  highly  irritated  by  the  preceding  in- 
flammation, and  therefore  most  susceptible  to  the  fur- 
ther reception  of  the  infections  {appendicitis  suppura- 
tiva perforativa) . 

But  there  may  also  be  a  suppurating  nucleus,  which, 
by  forming  adhesions  and  pushing  them  before  itself,  at 
last  generates  a  partition-like,  shut-off  pus  focus.  Then 
the  membranes,  originally  very  thin,  have  a  chance  to 
distend  gradually  and  gain  strength  by  additional  adhe- 
sive formation  {encysted,  isolated  appendicular  abscess). 

Finally,  there  may  ensue  ulceration  of  the  mucous 
membrane,  which  deepens  gradually  in  a  funnel-like 
shape.  The  blood-vessels,  possessing  but  scant  anasto- 
mosis, are  only  too  readily  inclined  to  the  formation  of 
thrombi  or  emboli,  so  that  there  results  an  anaemic 
infarct;  in  other  words,  necrosis  of  the  muscularis  and 
serosa — i.  e.,  a  perforation  hole.  Great  credit  belongs 
to  G.  R.  Fowler  for  having  studied  the  significance  of 
anastomosis  formation  in  this  most  important  relation. 

The  experience  of  many  authors,  my  own  included, 
shows  the  great  predilection  for  perforation  at  the  prox- 
imal end  of  the  appendix — that  is,  where  there  is  the 
scantiest  arterial  supply.  Kinks  and  adhesion  with  the 
adjacent  tissues  are  factors  favoring  inflammation. 
Faecal  concretions  are  to  be  regarded  as  the  results 
rather  than  the  causes  of  preceding  pathological  pro- 
cesses in  the  appendix. 

This  type,  which  is  to  be  called  gangrenous  appendi- 
citis, can  be  the  direct  consequence  of  the  perforation 
form.  But  it  can  also  encroach  upon  the  appendix  in  its 
whole  extent  at  once.  Then  the  organ  is  found  in  the 
midst  of  decomposed  pus,  mutilated  into  a  greenish- 


IS  APPENDICITIS   A   SURGICAL   DISEASE?  13 

black  band-shaped  fragment,  the  connection  of  which 
with  the  csecum  is  entirely  severed. 

In  all  these  various  types  of  a  suppurative  character 
a  spontaneous  favorable  termination  may  occur,  just 
the  same  as  it  occurs  in  infectious  processes  in  other 
parts  of  the  body.  But  it  can  not  be  disputed  that  such 
occurrences  are  extremely  rare.  The  abscess  may  be 
evacuated  through  the  abdominal  wall,  as  well  as  through 
the  intestine,  the  latter  possibility  being  the  most  fre- 
quent. It  may  also  happen  that  pus  foci,  especially  if 
encysted,  are  absorbed  after  being  thickened  and  hav- 
ing undergone  fatty  degeneration.  This  can  be  expect- 
ed so  much  easier  if  the  bacteria  contained  by  the  pus 
died  out,  so  that  the  pus  lost  its  virulence.  If  the 
appendix  be  gangrenous,  however,  such  possibilities  can 
but  very  rarely  be  expected. 

It  is  evident  that  these  various  tjrpes  can  not  always 
be  kept  asunder,  but  that  one  often  passes  into  another. 
This  consideration  leads  us  to  the  most  important  point, 
that  the  difference  of  type  mainly  depends  upon  the 
stage  in  which  the  appendix  is  made  accessible  to  ocu- 
lar inspection.  This  being  possible  only  after  the  abdo- 
men is  opened,  it  is  self-understood  that  the  different 
pathological  conditions  vary  in  proportion  as  they  de- 
volve upon  an  advocate  of  early  or  lat^e  surgical  inter- 
ference. 

If  the  abdomen  is  opened  at  an  early  stage,  the  fol- 
lowing state  is  often  found : 

The  c»cal  surface,  as  well  as  the  adjacent  intestines, 
show  absolutely  normal  conditions.  After  the  caput  coli 
is  lifted  off',  the  appendix  is  found  to  be  a  rigid,  firmly 
outstretched  organ  of  the  circumference  of  an  index 
finger.    It  may  properly  be  called  an  appendix  in  a  state 


14  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

of  erection.  By  thin  fibrinous  exudations  it  becomes 
adherent  to  its  vicinity.  Its  general  color  is  dark  red, 
but  in  some  places  there  are  yellow-grayish  foci,  just  like 
those  seen  in  panaritium  which  is  near  perforation,  the 
appendix  wall  having  become  so  thin  by  ulceration  that 
it  is  translucent,  and  the  intra-appendicular  pus  is  vis- 
ible. But  there  are  no  well-pronounced  external  signs 
of  perforation  (Fig.  5). 

Such  an  appendix,  after  being  removed,  shows  its  in- 
terior filled  with  a  decomposed  pulp  of  an  offensive  odor, 
which  mainly  consists  of  pus,  blood  coagula,  and  ne- 
crotic fragments  from  the  mucous  membrane.  The 
muscularis  is  necrotic  in  various  spots  and  the  serosa 
is  extensively  inflamed.  This  condition  represents  a 
true  empyema,  or,  as  we  may  properly  term  it, 
pyappcndix,  analogous  to  pyothorax,  pyosalpinx,  etc. 
(Fig.  6). 

If  in  such  cases  operative  steps  are  omitted  the  lapse 
of  an  hour  may  cause  a  small-calibred  perforation,  fol- 
lowed by  fulminant  sepsis,  or  slow-forming  gangrene 
may  come  on,  with  the  same  final  result. 

On  the  other  hand,  the  increase  of  the  intra-appen- 
dicular pressure  may  have  succeeded  in  extruding  the 
appendicular  contents  into  tlie  caecum.  But  even  under 
such  apparently  favorable  circumstances  it  certainly 
often  happens  that  the  appendicular  walls  being  so  much 
infected,  the  near  tissues  have  absorbed  so  much  virus 
that  further  peritoneal  infection  can  not  be  stopped  even 
by  eliminating  the  original  noxiousness. 

We  have  to  consider,  in  conclusion,  what  is  called 
"  chronic  appendicitis,^'  the  frequent  result  of  an  appen- 
dicitis which  took  a  "  favorable  course  "  after  internal 
treatment. 


IS   APPENDICITIS   A   SURGICAL   DISEASED 


15 


This  type,  which  is  also  frequently  termed  relapsing 
appendicitis,  is  characterized  by  a  thickening  of  the 
whole  sac,  which  is  filled  with  a  copious  quantity  of 
viscid  mucus,  sometimes  mixed  with  pus.  At  some 
points  there  arc  ampulla-like  dilatations,  due  to  the 
presence  of  turns,  kinks,  or  strictures  in  the  canal. 
Thus  the  expulsive  power,  so  small  in  itself,  on  account 
of  the  scantiness  of  muscular  elements,  is  so  much  more 


Fig.    5. — Pyappendix,     remo\cd 
during  an  acute  attack. 


Fig.  6.— Beginning  perforation  in  pyap- 
pendix; extensive  necrosis  of  mu- 
cosa and  muscularis  eleven  hours 
after  tlie  beginning  of  the  first  clinical 
symptoms. 


diminished  that  decomposition  of  the  contents  and  re- 
newed inflammatory  manifestations  must  necessarily 
follow. 

It  is  customary  to  theoretically  distinguish  this  type 
from  recurrent  appendicitis,  defining  recurrent  appen- 


1(J  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

dicitis  to  mean  that  after  an  acute  attack  and  the  disap- 
pearance of  symptoms,  a  second  attack  takes  place  after 
a  free  interval,  while  in  relaps- 
ing appendicitis  there  is  no 
free  interval,  the  patient  never 
being  completely  normal  and 
there  being  a  tendency  to 
numerous  exacerbations. 

This    differentiation,    how- 
ever, is  a  rather  arbitrary  one, 

Fig.  7— Fibrous  degeneration  of  and  wllilc  it  SCemS  to  bc  justi- 
appendix.  Tubercular  ulcer.  g^^  clinicallv,  it  CaU  UOt  be 
(Caseous  focus  on  the  tip.) 

upheld  from  the  standpoint  of 
pathology ;  and  the  term  "  chronic  appendicitis  "  may 
properly  cover  both  conditions. 

Among  the  rarer  types  there  may  be  mentioned  the 
actinomycotic  and  the  tuberculous  appendicitis.  The 
latter  undoubtedly  represents  a  much  more  frequent 
variety  than  is  generally  assumed.  Tuberculous  appen- 
dicitis has  not  infrequently  been  demonstrated  on  the 
autopsy  table  as  a  participating  manifestation  of  general 
tuberculosis.  In  connection  with  peritoneal  tuberculosis 
it  has  not  been  observed  so  often  (Fig.  7). 

The  following  cases  of  this  type  seem  to  me  deserv- 
ing mention : 

Case  I. — A  boy,  eight  years  of  age,  suffering  from 
the  caseous  form  of  peritoneal  tuberculosis,  which  was 
extensive  and  well  marked.  I  found  a  retroperitoneal 
caseous  stratum  of  the  thickness  of  an  index  finger; 
and  laparotomy  revealed  diffuse  tuberculosis  of  the  peri- 
tonaeum, intestine,  and  mesentery.  On  the  basis  of  the 
appendix,  which  was  deeply  imbedded  in  adhesions, 
there  was  a  cheesy  focus  of  the  size  of  a  cherry.  The 
patient  recovered  from  the  effects  of  the  extensive  opera- 


IS  APPENDICITIS  A   SURGICAL   DISEASE?  17 

tion,  which  consisted  in  the  thorough  removal  of  the 
foci,  but  four  weeks  tliereafter  he  succumbed  to  general 
tuberculosis. 

Case  II. — In  a  girl  of  thirteen  years,  in  whom  ex- 
ploratory laparotomy  had  revealed  tuberculosis  peri- 
tonei (light  ascitic  form),  a  tuberculous  appendix  was 
discovered.  The  patient,  being  of  a  rather  delicate  con- 
stitution, had  complained  of  pain  in  the  hypogastric 
region  more  than  a  year  before  the  operation.  Various 
members  of  the  fraternity  had  diagnosticated  dyspepsia, 
stomachal  catarrh,  chlorosis,  endocarditis  rheumatica, 
etc.  Six  months  before  the  operation  was  undertaken 
the  patient  was  taken  sick,  having  swallowed  a  large 
quantity  of  lemon  kernels.  According  to  the  statement 
of  a  most  reliable  colleague,  the  patient's  symptoms  had 
then  consisted  in  nausea,  pain  in  the  right  iliac  fossa, 
fever,  and  meteorism,  so  that  the  diagnosis  of  appendi- 
citis had  been  made.  The  treatment  was  expectant. 
After  two  weeks  the  acute  symptoms  disappeared,  but 
an  exudation  of  the  size  of  a  man's  fist  remained  in  the 
right  iliac  fossa.  Pressure  there  yielded  a  slight  pain- 
ful sensation.  The  abdomen  was  distended;  there  was 
constipation;  nausea  and  fever  were  absent.  The  ex- 
plorative laparotomy,  performed  in  the  linea  alba, 
showed  an  innumerable  quantity  of  nodules,  ranging 
from  the  size  of  a  pinhead  to  that  of  a  pea,  disseminated 
over  the  peritongeum.  The  apex  of  the  appendix,  which 
was  thickly  adherent  to  the  right  ovary  as  well  as  to 
the  colon,  showed  three  nodules.  In  the  small  pelvis 
were  a  few  teaspoonfuls  of  light  serum.  Eecovery  took 
place  without  reaction.  Six  years  have  elapsed  since, 
and  the  patient  has  remained  perfectly  well. 

But  there  is  undoubtedly  a  primary  form  of  tubercu- 
lous appendicitis,  and  I  trust  that  the  daily  progressing 
capacity  for  recognizing  the  various  types  of  appendi- 
citis, which  is  gained  and  trained  by  the  autopsy  in 
vivo,  will  soon  furnish  much  more  abundant  knowledge 
of  it.     I  can  not  help  thinking  that  in  former  years. 


18  IS  APPENDICITIS  A  SURGICAL  DISEASE? 

when  my  experience  in  appendicitis  was  more  limited, 
I  have  operated  upon  cases  which  gave  me  a  suspicion 
in  this  direction;  but  various  unfavorable  circumstances 
prevented  a  sufficiently  thorough  examination  into  the 
possibilities  of  tuberculosis.  Eecently,  however,  I  had 
a  chance  to  examine  and  to  operate  upon  two  well- 
marked  cases,  which  seem  to  me  of  interest. 

Case  III.- — A  girl  of  two  years  was  seized  with 
slight  peritoneal  symptoms  on  October  27,  1897.  Ac- 
cording to  the  family  physician's  report,  the  ileo-csecal 
region  had  been  particularly  sensitive  on  touch.  Treat- 
ment consisted  in  opium  and  ice  bag.  The  elevation  of 
temperature,  as  well  as  the  meteorism  and  the  tympa- 
nitic sound,  soon  disappeared  again,  but  a  slight  nausea 
persisted.  Finally,  the  patient  had  nearly  fully  recov- 
ered, when  suddenly,  on  JSTovember  17th,  she  became 
seriously  affected  with  peritoneal  symptoms.  There  was 
intense  vomiting  and  persistent  obstipation,  as  well  as 
an  elevation  of  temperature.  Soon  thereafter  collapse 
supervened,  so  that  intestinal  constriction  caused  by 
adhesions,  such  as  often  develop  after  peritonitis,  was 
thought  of. 

November  18th  I  found  the  following  state  present: 
Poorly  nourished  child,  showing  the  well-marked  symp- 
toms of  collapse.  Pulse,  160;  temperature  normal; 
meteorism.  A  dull  area,  comprising  the  whole  right 
iliac  fossa,  was  clearly  distinguished  from  that  of  the 
tympanitic  abdominal  sound. 

Diagnosis. — Gangrenous  appendicitis  after  previous 
simple  appendicitis.  Immediate  operation  at  St.  Mark's 
Hospital.  After  having  opened  the  abdomen  in  the 
ileo-ca3cal  region  the  intestine  was  found  to  be  of  a 
dark-red  color  and  covered  partially  with  fibrinous  exu- 
dation. Between  the  anterior  surface  of  the  caecum  and 
a  loop  of  the  jejunum  was  a  fresh  adhesion,  which  caused 
the  jejunum  to  bend  in  to  such  an  extent  that  it  could 
easily   explain   the   obstruction.      The   adhesions   were 


IS   APPENDICITIS   A   SURGICAL   DISEASE?  19 

loosened  under  great  difficulties,  the  surfaces  bleeding 
profusely.  Now,  between  this  area  a  thick  string,  reach- 
ing from  the  caecum  to  the  spinal  column,  having  about 
the  size  of  a  man's  thumb,  was  brought  into  view. 
After  being  shelled  out  from  the  surrounding  tissue, 
this  string  proved  to  be  the  appendix,  surrounded  by 
numerous  glands.  In  the  adjacent  portion  of  the  jeju- 
num small  nodules,  from  the  size  of  a  pinhead  to  that 
of  a  lentil,  were  found.  The  anaemic,  yellowish  appear- 
ance of  these  nodules  contrasted  strongly  with  the  dark 
red  tint  of  the  intestine.  Iodoform  gauze  packing. 
Fatal  termination,  five  hours  after  operation,  imder 
sj^mptoms  of  grave  collapse.  Examination  of  the  lacer- 
ated appendix  revealed  the  presence  of  a  small  caseotts 
focus  in  the  thickened  wall.  Altogether,  fourteen 
glands  had  been  removed,  three  of  which  had  undergone 
cheesy  degeneration.  The  presence  of  tuberculous  ba- 
cilli was  not  demonstrated,  but  the  macroscopical  con- 
ditions were  so  well  developed  that  there  could  hard- 
ly be  any  doubt  as  to  the  presence  of  tuberculosis.  No 
abnormities  were  found  in  any  other  organ  of  the 
body.- 

Case  IV. — A  man,  twenty-six  years  of  age,  of  a 
very  delicate  constitution,  highly  anaemic,  suffered  from 
disturbances  of  the  stomach  and  intestine  for  years. 
Last  year  one  of  his  two  brothers  died  from  pulmonary 
tuberculosis ;  the  other  one  has  recently  had  haemoptysis. 
The  painful  attacks,  which  could  be  localized  above 
the  large  curvature,  and  which  took  place  spontaneously 
as  well  as  on  pressure,  together  with  the  presence  of 
pyrosis,  nausea,  hyperacidity,  and  obstipation,  pointed 
toward  the  existence  of  a  stomachal  ulcer,  although 
hsematemesis  was  absent.  All  these  symptoms  yielded 
pretty  quickly  after  the  usual  treatment  for  gastric 
ulcer  was  instituted.  At  the  end  of  November,  1897, 
there  were  renewed  pain  in  the  right  iliac  fossa,  fever, 
vomiting.  The  family  physician  diagnosticated  ca- 
tarrhal appendicitis.  The  treatment  consisted  in  ice  bag 
and  opium.     Two  weeks  later  the  patient  was   again 


20  IS  APPENDICITIS   A   SURGICAL   DISEASE? 

able  to  get  up,  but  he  failed  to  recover  completely. 
There  were  also  slight  symptoms  characteristic  of  stom- 
achal ulcer.  In  the  middle  of  December  he  had  a 
second  violent  attack  of  the  same  kind  as  in  November. 
Medicamentous  therapeusis  again.  After  a  few  days 
apyrexy,  with  renewed  disturbances  in  stomach  and  in- 
testine. 

On  December  25,  1897,  after  being  admitted  to  St. 
Mark's  Hospital,  the  patient  showed  a  moderately  dis- 
tended abdomen,  tenderness  in  the  pyloric  region,  and 
well-marked  pain  in  the  right  iliac  fossa.  Eesistance 
and  dullness  correspondingly. 

Diagnosis.  —  Chronic  appendicitis.  On  December 
26th  oblique  incision  in  the  symphysis-rib  line.  The 
omentum,  which  is  found  covered  with  small  nodules, 
tightly  adheres  to  the  csecum,  so  that  it  must  be  divided 
to  permit  access  to  the  appendix.  Situated  crosswise 
toward  the  spine  the  appendix  is  found  imbedded  in 
glandular  tissue,  indiscriminably  changed  into  a  hard 
band.  Great  technical  difficulties  presented  themselves 
in  shelling  out  the  glands,  which  had  partially  undergone 
caseous  degeneration.  The  microscopical  examination, 
while  in  favor  of  tuberculosis,  did  not  discover  bacilli, 
nor  did  the  fgeces  contain  any  tubercular  bacilli.  I 
availed  myself  of  the  opportunty  of  the  intra-abdominal 
examination  of  the  stomach  to  make  a  careful  search, 
but  neither  by  inspection  nor  palpation  could  I  find  any- 
thing abnormal.     The  patient  recovered  slowly. 

Now,  four  months  after  operation,  he  has  a  mod- 
erate appetite,  and  is  free  from  fever  and  pain.  He  is 
still  very  anaemic,  but  there  are  no  positive  objective 
signs  of  any  disturbance. 

Whether  ulcus  ventriculi  really  existed  in  this  case 
I  do  not  regard  as  proved.  Without  denying  the  possi- 
bility of  it,  I  am  inclined  to  consider  all  the  more  or 
less  vague  stomachal  symptoms  as  indirect  expressions 
of  the  diseased  appendix,  the  ulcerative  process  perhaps 


IS   APPEiNDICITIS   A   SURGICAL   DISEASE?  21 

having  existed  for  a  long  time  without  causing  well- 
marked  local  manifestations. 

In  regard  to  the  study  of  actinomycotic  appendicitis, 
which  I  never  had  a  chance  to  observe,  I  refer  to  the  ex- 
cellent essays  of  Barth,  on  abdominal  actinomycosis 
{Verhandlung  der  freien  Vereinigung  der  Chirurgen 
Berlins,  1890,  Jahrg.  32,  S.  29)  ;  Partsch,  on  human 
actinomycosis  {Sammlung  Jclinischer  Vortrdge,  S.  306, 
307)  ;  Lanz,  on  perityphlitis  actinomycotica  (Bern, 
1893)  ;  Braun  {Correspondcnzhldttcr  des  drztlichen 
Vereins  von  Thiiringen,  1897);  and  Israel  {Verhand- 
lungen  der  freien  Vereinigung  der  Chirurgen  Berlins, 
1895,  S.  115). 

Wherever  mixed  infection  with  pyogenic  bacteria  has 
taken  place  the  picture  of  the  disease  is  veiled,  and  the 
chances  are  that  thus  the  character  of  this  type  is  gen- 
erally overlooked,  the  clinical  picture  of  it  not  essen- 
tially differing  from  that  of  common  appendicular  sup- 
purative processes. 

There  are  also  carcinomatous  or  sarcomatous  affec- 
tions of  the  appendix.  In  a  case  of  intra-abdominal 
adenocarcinoma  I  was  able  to  detect  secondary  nodules 
attached  to  the  serosa  of  the  appendix. 

In  a  case  of  fibrocarcinoma  I  noticed  a  retrograde 
perforation  caused  by  carcinomatous  \^ilceration,  the 
latter  having  corroded  serosa  and  muscularis,  so  that 
the  mucosa  could  be  lifted  up  by  a  probe  introduced 
from  without. 

On  considering  now  the  manner  in  which  the  ana- 
tomical changes  described  express  themselves  clinically, 
we  at  once  touch  the  sorest  point  of  the  controversies  on 
appendicitis.  There  can  be  no  doubt  that  it  is  the  ana- 
tomical basis  alone  on  which  a  scientific  standard  fun- 


22  IS   APPENDICITIS  A   SURGICAL   DISEASE? 

dament,  the  symptomatology  of  a  disease,  can  be  built. 
A  classification  of  appendicitis  into  light,  moderate,  and 
grave  cases,  as  is  suggested  by  some,  must  therefore,  even 
from  the  strictly  clinical  standpoint,  be  rejected.  The 
law  is  that  there  must  be  in  general  a  clinical  expres- 
sion for  any  tissue  change.  The  circumstance  that  in 
many  cases  such  expressions  fail  to  be  perceived  or  ex- 
plained properly  by  us  is  no  proof  of  their  non-existence. 
In  spite  of  the  difficulties  of  diagnosis  we  must  endeavor 
again  and  again  to  interpret  the  various  complex  symp- 
toms that  present  themselves  more  or  less  confusedly. 
It  will  be  only  after  such  patient,  thoughtful,  and  re- 
peated effort  that  we  shall  draw  in  our  minds  any  ade- 
quate picture  of  the  anatomical  condition  of  the  appen- 
dix. Only  thus  shall  we  be  able  to  further  the  under- 
standing of  this  immensely  important  disease.  It  can 
hardly  be  assumed  that  the  anatomical  changes  as  they 
were  described  would  show  a  marked  clinical  expression 
from  the  very  beginning.  On  the  contrary,  must  it  be 
imagined  that  this  intra-appendicular  crater  has  been 
silently  working  for  a  period  of  time  before  it  came  to 
the  explosion  of  the  first  attack.  So  there  is  actually  a 
more  or  less  symptomless  chronic  appendicitis,  the  acute 
exacerbation  of  which  leads  our  attention  to  the  exist- 
ence of  the  disease.  By  considering,  however,  the  many 
vague  symptoms,  often  protracted  during  years,  which 
a  number  of  histories  reveal,  we  should  not  feel  justified 
in  speaking  of  the  absolute  absence  of  symptoms  of  this 
preliminary  process.  We  should,  on  the  contrary,  real- 
ize that  we  have  not  as  yet  learned  to  interpret  these 
symptoms  properly.  How  often  do  we  find  complaints 
of  disturbances  of  the  stomach  and  intestine,  or  of  dis- 
eases of  the  liver,  kidneys,  or  bladder!  (Compare,  for 
instance,  the  history  of  Case  IV.) 


IS  APPENDICITiS   A  SURGICAL   DISEASE?  28 

If  women  are  concerned,  such  complaints  are  often 
disposed  of  as  being  of  hysterical  origin,  and  treatment 
of  the  adnexa  might  be  undertaken,  with  no  result  of 
course.  Likewise  may  a  number  of  nervous  disturb- 
ances, not  only  of  the  intestine,  but  also  of  the  circula- 
tory apparatus,  being  caused  by  reflex  irritation,  be 
derived  from  a  diseased  appendix.  If  we  compel  our- 
selves to  think  of  the  possibility  of  a  diseased  appendix 
in  all  cases  of  abdominal  disorder,  there  can  be  no 
doubt  but  that  we  shall  frequently  detect  some  clews, 
no  matter  how  meagre  they  may  be,  in  this  state.  Pal- 
pation and  percussion  oftentimes  fail,  but  there  is  fre- 
quently tenderness,  felt  spontaneously  as  well  as  on  pres- 
sure. Thus,  according  to  greater  knowledge,  we  could 
cease  to  speak  of  a  kind  of  latent  appendicitis  in  favor  of 
a  really  existing  chronic  appendicitis  showing  but  scanty 
symptoms. 

We  are  accustomed  to  use  the  term  appendicitis  as 
soon  as  there  is  a  typical  chain  of  symptoms,  as  they 
mark  themselves  more  or  less  distinctly  already  in  the 
simplest  form  of  appendicitis  (appendicitis  simplex), 
the  most  predominant  of  them  being  the  sudden  ac- 
cession of  intense  pain,  either  in  the  midst  of  perfect 
euphoria  or  after  a  short  period  of  indisposition.  In  the 
greater  majority  of  cases  this  pain  is  g^radually  located 
in  the  right  iliac  fossa.  But  there  are  cases  where  in 
the  beginning  it  is  concentrated  in  the  epigastrium  or 
the  umbilical  region.  As  a  rule,  it  first  occurs  on  the 
so-called  McBurney's  point,  or  at  the  exterior  margin 
of  the  rectus  muscle  in  the  middle  of  a  line  drawn  from 
the  umbilicus  to  the  anterior  superior  spine  of  the  ilium. 
This  most  constant  symptom  is  accompanied  by  ab- 
dominal tenderness  and  very  frequently  by  nausea  and 
vomiting.     Slight  elevation  of  temperature  is  also  fre- 


24  IS   APPENDICITIS   A  SURGICAL   DISEASE? 

quently  present,  but  it  may  also  be  absent,  just  the 
same  as  vomiting  or  nausea.  The  pulse  may  be  but  lit- 
tle accelerated.  Vomiting  and  nausea  usually  do  not 
precede  the  pain,  as  in  indigestion,  but  follow  it.  There 
is  obstipation  in  the  majority  of  cases,  but  diarrhoea  is 
also  frequently  observed. 

In  most  cases  a  more  or  less  marked  resistance  in 
the  appendicular  region  can  be  palpated.  There  is  fre- 
quently the  sensation  of  pressing  a  rigid  formation  of 
the  shape  of  a  small  sausage.  A  most  constant  symptom 
is  the  more  or  less  marked  dullness,  which  corresponds 
to  the  thickening  of  the  swollen  tissues  and  which  does 
not  at  all  necessarily  imply  faecal  stasis  as  a  cause. 

In  many  cases  these  symptoms  subside  after  the  first 
three  or  four  days.  But  in  the  great  majority  of  cases 
there  remains  much  tenderness  of  the  appendicular  re- 
gion, and  sooner  or  later  a  second  attack  follows,  which 
may  end  in  resolution  again,  like  the  first  one,  but 
may  just  as  well  assume  the  circumappendieular,  phleg- 
monous, or  perforative  character. 

In  periappendicitis  there  are  virtually  the  same 
symptoms  as  in  simple  appendicitis,  but  they  are  much 
more  pronounced.  There  being  in  fact  a  circumscribed 
peritonitis,  a  palpable  tumor  can  generally  be  defined 
in  the  right  iliac  fossa.  The  inflammatory  exudations 
and  the  serous  infiltration  of  the  sphere  immediately  sur- 
rounding the  appendix  naturally  make  the  dullness  more 
pronounced  than  in  simple  appendicitis.  The  stasis  of 
the  csecal  contents,  caused  by  the  compression,  may  fur- 
ther enlarge  the  extent  of  the  dullness.  But  even  if 
the  ca?cum  be  entirely  evacuated,  the  dullness  will 
persist. 

The  tumor  may  undergo  resolution  in  three  or  four 


IS   APPENDICITIS  A   SURGICAL   DISEASE?  25 

days,  just  as  in  simple  appendicitis,  but  there  may  as 
well  be  suppuration. 

In  phlegmonous  appendicitis  we  may  be  eon- 
fronted  with  the  same  symptoms  during  the  first  thirty- 
six  hours  as  in  appendicitis  simplex  or  periappendi- 
citis, so  that  a  differential  diagnosis  at  this  period  is 
entirely  impossible.  The  temperature  may  also  oscillate 
between  98.6°  and  103.2''  F.,  and  the  pulse  need  not 
necessarily  exceed  90.  There  is  a  real  chill  sometimes. 
On  account  of  the  well-marked  meteorism  the  tumor 
sometimes  can  not  be  palpated.  But  the  reliable  guide — 
dullness — is  never  absent.  I  am  confident  that  in  most 
cases  the  presence  of  appendicitis  can  be  diagnosticated 
without  relying  on  the  dullness,  but  it  should  always 
be  taken  into  consideration  as  an  additional  proof,  and 
if  the  question  of  differentiation  should  turn  up  it  will 
be  of  the  greatest  importance.  I  am  sure  that  some- 
times it  was  only  the  dullness  that  led  me  into  the 
right  direction.  Particularly  where  the  appendix 
reached  far  down  into  the  pelvis,  a  small  but  dis- 
tinct dull  area  above  Poupart's  ligament  indicated  the 
character  of  the  disease,  which,  as  was  corroborated 
always  by  the  subsequent  operation,  has  so  far  never 
misled  me. 

There  is  sometimes  only  half  a  tablespoonful  of  pus 
present,  and  in  such  cases  it  happened  to  me  repeatedly 
that,  after  having  exposed  the  upper  surface  of  the 
csecum,  on  a  superficial  view  apparently  normal  intra- 
abdominal conditions  presented  themselves,  so  that  at 
first  the  impression  prevailed  as  if  the  operation  had 
been  entirely  uncalled  for.  But  after  going  further 
down  and  lifting  off  the  caecum  a  fibrinous  membrane 
of  moderate  thickness  was  found,  which  ended  on  the 


26  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

psoas  muscle.  These  fibrinous  deposits  often  tell  of  an 
underlying  exudate,  palpation  of  which  is  prevented  by 
the  overlapping  csecum,  which,  on  account  of  its  con- 
taining quite  an  amount  of  air,  prohibits  the  palpating 
fingers  from  feeling  a  resistance.  But  the  dull  sound 
could  not  be  suppressed  by  the  tympanitic  area.  By 
pulling  off  the  posterior  caecal  surface  carefully  and 
introducing  a  grooved  director  gently  into  the  fibrinous 
stratum,  a  small  amount  of  pus  was  discharged  from  a 
cavity  the  walls  of  which  were  created  by  the  agglu- 
tination of  intestine,  omentum,  and  the  inflamed  non- 
perforated  appendix. 

In  appendicitis  perforativa  suppurativa  the  same 
chain  of  symptoms  may  be  present  as  in  simple  appen- 
dicitis. In  the  majority  of  cases  the  vomiting  may  be 
more  constant  and  intense,  and  the  meteorism  more  de- 
veloped. A  distinct  resistance  can  be  felt,  which,  how- 
ever, if  the  meteorism  becomes  extensive,  may  cease  to 
be  palpable.  But  in  such  an  event  the  presence  of  an 
exudate,  no  matter  how  small  it  is,  can  be  proved  as 
projecting  from  the  meteoristic  area. 

Chills  are  more  frequently  observed  than  in  the  other 
varieties,  and  furthermore  the  general  disturbances  of 
the  body  are  more  pronounced  from  the  beginning.  The 
fever  is  atypical,  and  might  as  well  be  moderate  as  high. 
In  virulent  cases  it  might  be  normal  in  the  beginning, 
and  in  benign  cases  at  the  later  period.  The  pulse  is 
generally  accelerated,  but  need  not  necessarily  exceed 
90  at  the  early  stage. 

All  these  manifestations  may  also  subside,  and  pro- 
tecting adhesions  may  form  around  the  burst  appendix, 
which  shut  off  the  purulent  contents  from  the  abdominal 
cavity.    If  these  adhesions  are  firm  and  solid,  pulse  and 


IS  APPENDICITIS   A   SURGICAL   DISEASE?  27 

temperature  may  be  entirel}'  normal,  because  there  is  no 
absorption  of  pus  products.  Such  accumulations  may 
thus  exist  for  a  long  time,  the  inconvenience  caused  by 
them  being  so  insignificant  sometimes  that  patients  thus 
afflicted  may  go  about  for  weeks,  deplorable  witnesses  of 
the  curative  power  of  expectant  therapy,  until  either  a 
scalpel  or  Nature,  by  perforating  through  the  point  of 
least  resistance,  shows  mercy. 

But  often  the  seemingly  incorrect  manifestations  are 
followed  by  those  of  grave  sepsis  with  such  rapidity  that 
the  fate  of  the  patient  may  be  sealed  inside  of  a  few 
hours. 

The  appendicitis  gangrgenosa  in  its  initial  stage  may 
begin  just  the  same  way  as  the  other  varieties,  so  that, 
unfortunately,  during  the  first  twenty-four  or  thirty-six 
hours  there  is  entire  ignorance  as  to  the  significance  of 
the  process.  I  say  unfortunately,  because  this  ignorance 
generally  costs  the  patient's  life. 

When  the  peritoneal  sepsis  manifests  itself  by  ab- 
dominal swelling,  when  there  is  constant  vomiting, 
sometimes  of  a  faecal  character,  when  faces  and  urine 
are  retained,  the  pulse  goes  up  and  the  temperature 
down,  then,  of  course,  there  is  no  more  doubt  as  to  the 
fatal  significance  of  the  case.  Then  it  is  generally  not 
long  before  the  face  shows  the  Hippocratic  expression, 
the  nose  and  extremities  become  cold  and  clammy,  and 
the  compressible  pulse  points  to  the  intoxication  of  the 
heart  muscle.  The  tongue  is  usually  of  an  intensely  red 
color  and  sometimes  coated.  Unquenchable  thirst  and 
singultus  torment  the  patient,  and  in  two  or  three  days 
after  the  onset  of  the  attack  the  tragedy  ends. 

But  in  the  gangrenous  form,  as  well  as  in  the 
phlegmonous  or  perforative  variety,  it  need  not  neces- 


28  IS    APPENDICITIS  A   SURGICAL   DISEASE? 

sarily  come  to  the  physical  signs  of  peritonitis.  The 
abdomen  may  remain  flat,  and  rapid  death  may  occur 
through  foudroyant  sepsis.  But  only  in  a  small  number 
of  cases  of  this  kind  does  this  plexus  of  symptoms  mark 
itself  so  early  as  during  the  first  few  hours.  Nothing 
has  ever  taught  me  the  insufficiency  of  our  diagnostic 
means  so  impressively  as  these  terribly  rapid  cases,  in 
which  the  clinical  symptoms  were  in  no  proportion  to 
the  pathological  changes,  for  which  the  surgical  opera- 
tion could  do  no  more  than  to  expose  the  fatal  intra- 
abdominal lesions. 

In  honor  of  the  medical  fraternity  in  the  native  city 
of  the  appendix  science,  be  it  said  here  that  there  is  a 
not  .  inconsiderable  number  of  physicians,  increasing 
every  year,  who  appreciate  this  gloomy  state  of  affairs 
to  its  full  extent.  Their  experience  gained  in  surgical, 
operations  for  appendicitis  has  taught  them  the  dan- 
ger of  a  delaying  policy.  They  fear  bacteria  more  than 
they  do  the  scalpel,  and  consequently  they  have  more 
confidence  in  operative  interference  than  in  palliative 
treatment.  It  happens  even  not  too  infrequently  nowa- 
days that  in  the  holy  ardor  for  the  good  cause  there  is 
too  much  good  done  in  this  direction,  and  that  surgeons 
sometimes  are  called  upon  to  operate  when  coprostasis 
only  is  present,  a  condition  which,  of  course,  readily 
yields  to  the  most  unsurgical  treatment.  Such  hyper- 
activity need  not  disturb  us.  An  early  operation  is  illus- 
trated in  the  following  case : 

Case  V. — A  slenderly  built  girl  of  twenty-five  years, 
who  had  suffered  from  slight  attacks  twice  before  dur- 
ing last  year,  was  attacked  suddenly  in  the  morning  of 
April  7,  1898,  with  moderate  pain  in  the  right  iliac 
fossa,  which  later  on  radiated  toward  the  whole  abdo- 


IS   APPENDICITIS   A   SURGICAL   DISEASE?  29 

men.  The  physician,  who  was  called  a  few  hours  after 
the  onset  of  the  pain,  insisted  upon  the  immediate  re- 
moval of  the  appendix.  The  patient  was  transferred  to 
St.  Mark's  Hospital,  where  the  following  state  was  pres- 
ent at  5  P.  M.  of  the  same  day :  The  patient  shows  ap- 
parently few  signs  of  disease.  There  is  slight  nausea 
and  obstipation.  Spontaneous  pain  of  considerable  in- 
tensity sometimes  occurs.  The  rectal  temperature  regis- 
ters 37.8°,  and  the  regular  pulse  is  92.  Inspection  of  the 
abdomen  reveals  nothing  abnormal.  Palpation  states 
slight  indistinct  resistance  in  the  appendicular  region. 
The  same  area  is  very  tender  to  touch.  The  patient 
declines  the  operation,  claiming  not  to  be  sick  enough. 
She  sits  erect  in  bed,  as  it  is  impossible  for  the  nurses 
to  keep  her  recumbent.  This  position  does  not  seem 
to  discomfort  her  as  long  as  there  is  interval  from  pain. 
She  threatens  to  get  up,  but,  impressed  by  the  implora- 
tions  of  her  intelligent  relatives,  she  at  last  consents  to 
the  operation,  which  was  performed  at  6  p.  m.,  and  re- 
vealed the  following  state :  The  abdominal  cavity  is  en- 
tirely normal.  The  empty  caecum  has  even  a  pale-red 
color.  While  trying  to  lift  it  off,  a  thin,  fibrinous  stra- 
tum is  discovered,  which  adheres  to  the  posterior  csecal 
surface  on  one  side  and  to  the  peritonseum  of  the  right 
iliac  fossa  of  the  other,  thus  surrounding  the  rigidly 
erected  appendix,  which  has  a  dark-red,  and  on  some 
points  a  grayish-yellow  appearance.  The  thickness,  as 
well  as  the  length,  corresponds  to  the  index  finger  of  a 
man.  There  are  no  distinct  external  signs  of  perfora- 
tion, but  there  is  a  well-marked  foetid  odor  of  the  appen- 
dix even  before  its  removal.  After  being  removed,  the 
canal  shows  a  pulpy  mass,  consisting  of  pus,  necrotic 
tissue,  and  blood-corpuscles,  filling  up  its  interior.  The 
mucous  membrane  appears  lacerated  through  ulceration, 
and  a  probe  pushed  against  the  lacerated  points  can  be 
seen  from  without,  the  great  translucency  of  the  appen- 
dix wall  indicating  the  cobweblike  thinness  of  the  por- 
tion of  the  serosa  which  still  prevented  perforation. 

The  stump  was  not  sewed  up  in  its  entirety.    After 
having  been  dusted  with  iodoform  powder  it  was  sur- 


30  IS  APPENDICITIS   A   SURGICAL   DISEASE? 

rounded  with  small  strips  of  iodoform  gauze.  Three 
quarters  of  the  abdominal  wound  were  closed.  There 
having  been  no  further  symptoms  of  infection,  and  the 
patient  complaining  of  nothing  else  than  hunger,  the 
gauze  is  removed  two  days  later.  The  small  gape  in 
the  abdominal  wall  is  drawn  together  above  a  piece  of 
gauze  by  means  of  aseptic  adhesive-plaster  strings.  Re- 
covery was  uninterrupted. 

In  view  of  the  high  pressure  under  which  the  thin 
and  extremely  translucent  wall  of  the  ulcerated  appen- 
dix was,  it  could  be  fairly  assumed  that  the  perforation 
might  have  taken  place  inside  of  a  few  hours.  So  it  was 
the  energy  of  the  family  physician  which  prevented  the 
highly  virulent  contents  from  flowing  into  the  free 
abdominal  cavity. 

I  suppose  that  a  priori  a  number  of  colleagues 
would  have  been  inclined  to  blame  this  family  physician 
because  he  proposed  operating  in  this  early  stage.  Here 
we  are  confronted  with  the  most  delicate  and  important 
point  of  the  appendicitis  question.  On  this  obscure 
point,  the  uncertainty  of  the  diagnosis  in  reference  to 
the  stage  and  the  toxic  potency  of  the  inflammatory 
process,  hinge  all  the  bitter  controversies  as  to  therapy; 
which  show  an  increasing  rather  than  decreasing  harsh- 
ness in  condemning  the  early  operation.  On  the  basis  of 
my  own  comparative  clinical  anatomical  experience,  I 
am  forced  to  assume  that  in  about  half  of  the  cases  the 
clinical  picture  of  appendicitis  is  not  so  well  marked 
that  any  decisive  conclusion  can  be  drawn  as  to  the 
status  of  the  pathological  change.  That  we  should 
reach  such  perfection  of  diagnosis  is  most  desirable, 
but  cruel  experience  teaches  that  we  have  not  attained 
it.    The  surgeon  who,  before  opening  the  abdominal  cav- 


IS  APPENDICITIS  A  SURGICAL   DISEASE?  31 

it}',  will  try  to  picture  to  himself  its  true  condition,  and 
who  afterward  has  a  chance  to  compare  his  imagined 
picture  with  the  facts,  must  agree  with  me  in  this  con- 
fession of  ignorance. 

Now  the  surgeon  at  last  is  compelled,  in  observing 
the  return  of  cases  insufficiently  judged  before  operation, 
to  the  conviction  that  from  the  presence  of  apparently 
mild  symptoms  a  decisive  conclusion  as  to  the  relative 
innocence  of  the  inflammation  can  hardly  ever  be  drawn 
during  the  first  twenty-four  hours.  On  the  surgeon  the 
conviction  is  forced  that  in  every  case  of  appendicitis 
there  must  be  an  infection,  and  that  if  the  infecting 
material  has  not  trespassed  beyond  the  appendix,  yet  it 
may  do  so  at  any  moment.  And  after  it  has  done  so 
the  power  of  the  knife  is  limited.  The  following,  being 
one  among  many,  is  a  typical  case  of  this  kind : 

Case  VI. — A  very  strong  laborer  thirty-six  years 
of  age  suddenly  noticed  at  6  A.  m.  on  January  12, 
1898,  in  getting  up,  a  pain  in  the  umbilical  region, 
which  radiated  toward  the  right  iliac  fossa  in  the  course 
of  the  afternoon.  The  patient  had  always  been  well 
before,  particularly  so  the  previous  evening.  During 
the  night  he  had  slept  well  as  usual.  It  was  only  in  the 
afternoon  of  the  day  he  was  attaclved  that  he  felt  unable 
to  work.  During  the  night,  from  the  12th  to  the  13th, 
he  had  a  sensation  of  augmented  disconfifort  and  inter- 
mittent colicky  attacks  of  moderate  intensity.  On 
January  13th,  at  4  p.  m.,  a  physician  was  called  in,  who, 
in  view  of  finding  a  nearly  normal  pulse  and  tempera- 
ture, felt  justified  in  diagnosticating  indigestion.  To 
the  administration  of  opium  and  pepsin  the  pain  yielded 
promptly.  On  the  morning  of  January  14th  suddenly 
intense  vomiting  and  distention  of  the  abdomen  set  in, 
and  onl}''  then  was  the  suspicion  of  appendicitis  en- 
tertained. After  a  consultation  the  patient  was  trans- 
ferred to  St.  Mark's  Hospital  late  in  the  afternoon  of 


32  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

January  14th.  It  had  not  been  intended  to  operate 
on  the  patient  on  the  same  day.  Merely  by  accident 
I  had  a  chance  to  see  this  patient  shortly  after  his  ar- 
rival. The  state  present  at  that  time  was  the  following: 
A  very  strong  man,  an  expression  of  suffering,  vomit- 
ing moderately  often;  temperature,  37.4°;  pulse,  112. 
Abdomen  distended  and  painful  to  touch.  The  pres- 
ence of  meteorism  prevented  palpation  of  either  tumefac- 
tion or  resistance,  but  the  distinct  dullness,  emanating 
well  defined  from  the  tympanitic  area,  pointed  to  the 
presence  of  an  exudate.  I  advised  immediate  operation. 
After  washing  out  the  stomach  and  administering  a 
hypodermic  saline  infusion  the  abdomen  was  opened  in 
the  ileo-cagcal  region  by  an  extensive  oblique  incision. 
At  once  there  sprang  forth  several  dark-red  loops  of 
the  ileum,  which  were  covered  with  flocks  of  fibrin  and 
cohered  loosely  by  fibrinous  membranes.  On  slight 
touch  the  intestine  bled.  Sero-pus  of  foetid  odor  pours 
forth  between  the  loops.  After  having  pulled  forward 
the  intestine,  which  was  flooded  with  hot  salt  water, 
while  fibrinous  flocks  were  wiped  off  by  means  of  sterile- 
gauze  mops,  the  adhesions  were  severed.  Then  the  in- 
testine was  protected  with  hot  compresses.  The  caecum, 
in  order  to  search  for  the  appendix,  is  drawn  out  widely, 
and  a  small  focus,  containing  about  one  tablespoonful 
-of  grayish-yellow  stinking  pus,  is  evacuated  from  the 
cavity  to  the  right  of  the  lumbar  vertebral  column.  ISTow 
the  greenish-black  appendix,  transversely  situated  toward 
the  iliac  bone,  is  recognized.  Up  to  its  csecal  junction 
it  is  smashed  with  the  branches  of  a  forceps,  so  that 
ligation  of  it  is  out  of  question.  So  it  is  carefully 
removed,  and  the  vicinity  packed  with  iodoform  gauze, 
after  another  careful  revision  of  the  csecum,  done 
under  permanent  hot  irrigation.  Anesthesia,  admin- 
istered after  Schleich  No.  1,  was  excellent.  Great  im- 
provement followed  the  operation.  Pulse  even,  of  good 
quality,  till  the  following  morning  showed  the  well- 
marked  picture  of  peritoneal  sepsis.  Fatal  termination 
on  the  same  evening. 


IS  APPENDICITIS  A   SURGICAL   DISEASE?  33 

Could  this  patient  have  been  saved?  Probably,  pro- 
vided he  could  have  been  submitted  to  operation  on  Janu- 
ary 12th,  because  on  the  14th  it  was  far  too  late,  as  the 
condition  at  the  operation  showed.  But  on  the  12th  the 
patient  did  not  yet  feel  obliged  to  send  for  a  physician. 
And  on  the  14th,  half  an  hour  before  the  opening  of 
the  abdomen,  which  revealed  so  grave  an  anatomical 
condition,  several  colleagues  were  undetermined  whether 
the  indication  for  an  operation  was  yet  present.  In 
view  of  this  anatomical  condition  it  can  be  fairly  as- 
sumed that  gangrene  and  peritoneal  infection  had  been 
developed  as  early  as  January  13th. 

The  question  arises  now:  Is  the  first  physician  to 
be  blamed?  I  say,  No.  It  is  by  no  means  necessary 
that  a  gangrenous  process  should  manifest  itself  by  well- 
marked  clinical  symptoms  at  its  beginning.  Why  should 
it?  Until  the  death  of  the  cells  is  completed  twelve  or 
twenty- four  hours  may  elapse,  and  even  after  necrosis  of 
the  cells  is  complete  it  is  not  at  all  safe  to  assume  that 
the  toxic  elements  absorbed  by  the  lymph  channels  should 
at  once  make  themselves  conspicuous  in  well-marked 
clinical  manifestations.  Thus  it  can  be  seen  that  from 
the  surface  we  can  not  know  the  gloomy  mole  work  that 
culminates  in  the  infection  of  the  peritonjeum.  Vice 
versa,  there  is  no  conclusion  to  be  drawn  from  slight 
clinical  manifestations  as  to  the  presence  of  an  innocent 
simple  form  of  appendicitis,  when  we  could  safely  wait 
until  the  rise  of  temperature  and  other  aggravations  of 
the  symptoms  would  indicate  that  a  stage  of  higher  viru- 
lence has  come  now.  How  beautiful,  if  such  were  the 
real  facts !  But  it  is  an  utter  fallacy.  Then  it  is  true 
that  the  carrier  of  the  infection  can  be  removed,  but  the 
infection  of  the  abdominal  cavity  itself  can  not  be  un- 
3 


34  IS   APPENDICITIS  A   SURGICAL   DISEASE? 

done.  To  expect  that  after  the  elimination  of  the  sep- 
tic appendix  the  septic  peritonitis  should  also  cease  to 
exist,  would  be  like  the  wounded  warrior,  who,  after 
the  bullet  is  extracted,  is  triumphant,  and  cares  nothing 
for  the  shot  canal,  nor  for  the  tissue  destruction  caused 
by  the  bullet. 

In  some  cases  the  comparison  with  panaritium,  where 
the  patient,  besides  his  pain,  does  not  necessarily  feel 
any  general  disturbance,  can  not  be  helped. 

For  this  diagnostic  deficiency  not  the  medical  man 
but  medical  science  is  responsible.  No  man  can  give 
more  than  he  has.  But  it  can  be  demanded  that  the 
internists  should  give  more  attention  to  the  knowledge 
gained  by  the  surgeons  during  their  autopsies  in  vivo. 
It  is  not  the  technique  of  the  surgeon  which  I  have  in 
view.  No,  it  is  the  experienced  surgical  observer,  who 
watches  the  appendix  in  all  its  ways  and  doings  so 
much  more  closely,  who  sees  it  in  all  its  different  forms 
and  stages,  who  touches  and  inspects  it  intra-abdominal- 
ly.  The  same  standpoint  would  then  force  itself  upon 
many  internes,  and  they  would  cease  to  hold  that  "  ap- 
pendicitis in  general  is  a  light  disease,  the  treatment  of 
which  consists  in  ice  and  opium.  If  "exceptionally  peri- 
toneal manifestations  should  present,  operative  treat- 
ment might  be  considered.^'  I  do  not  have  in  view  those 
colleagues  who  disavow  the  surgeon  a  tout  prix,  and  who 
extol  themselves  with  a  smile  of  superiority  that  they 
have  cured  all  their  cases  of  appendicitis  by  their  nihil- 
istic modus  operandi.  But  how  many  such  cases  termi- 
nate fatally  without  being  diagnosticated  properly! 
What  would  these  antisurgeons  say  if  in  all  these  cases 
they  had  been  cited  before  the  pitiless  autopsy  forum  ? 

No,  I  have  in  view  those  unprejudiced  colleagues 


IS    APPENDICITIS    A   SURGICAL   DISEASE?  35 

who  collect  notable  experience  from  sufficient  clinical 
material.  There  can  be  no  question  that  such  colleagues 
see  a  not  inconsiderable  number  of  cases  of  appendicitis 
recover.  The  statistics  on  such  recoveries  are  simply 
overwhelming,  and  in  some  clinics  even  the  enormous 
percentage  of  ninety  is  spoken  of. 

If,  however,  those  so-called  recoveries  are  closely 
analyzed,  it  will  be  found  that  most  of  these  patients 
who  overcame  simple  appendicitis  were  not  observed 
any  further.  But  it  can  well  be  assumed  that  the  appen- 
dix in  all  those  "  cured  "  cases  had  undergone  patho- 
logical changes,  which  sooner  or  later  caused  a  second 
or  third  attack.  Then  such  a  case  might  figure  in  the 
statistics  as  a  case  "  which  was  cured  three  different 
times."  Or  the  patient  might  have  succumbed  to  the 
second  attack  just  as  well. 

Sonnenburg  alone  observed  recurrence  of  the  inflam- 
matory process  thirty-two  times  in  fifty-one  cases,  which 
gives  a  percentage  of  sixty-three. 

It  seems  to  me  that  in  patients  who  report  a  first, 
well-overcome  attack,  the  physician  is  particularly  ready 
to  resort  to  the  expectant  treatment.  It  is  only  when  a 
grave  toxsemic  picture  develops  that  in  his  anxiety  he 
may  at  last  advise  an  operation  as  an  ultimate  resort. 
But  then  it  is  much  too  late,  and  the  operation  being  un- 
successful, the  internist  believes  he  has  added  further 
proof  to  the  theory  that  operative  interference  in  ap- 
pendicitis is  a  fraud. 

The  surgeon,  of  course,  will  hold  altogether  differ- 
ently, and  very  properly  makes  the  proerastinator  re- 
sponsible for  the  fatal  outcome.  But  this  case  now 
swells  the  surgical  list  of  casualties  and  the  internist 
goes   out   unconcerned,   while   virtually   the   mortality 


36  IS   APPENDICITIS   A    SURGICAL   DISEASE? 

number  of  this  case  belongs  to  his  account.  There 
is  to  be  considered  furthermore  the  large  number  of 
patients,  occupying  the  wards  of  hospitals,  who  are  ad- 
mitted under  the  vague  diagnosis  of  peritonitis,  internal 
obstruction,  etc.  How  often  would  appendicitis  be  dem- 
onstrated if  an  autopsy  were  always  performed !  If 
such  cases  terminate  fatally  under  internal  treatment 
they  will  not  be  credited  to  the  appendicitis  list  of  cas- 
ualties. And  if  such  desperate  cases  drift  into  the  hands 
of  a  surgeon,  who,  adhering  to  the  principle  that  such 
patients  have  nothing  to  lose  and  everything  to  gain, 
run  the  great  risk  of  an  operation,  there  will  naturally 
be  a  very  small  number  of  recoveries.  So  all  the  surgeon 
could  do  was  to  swell  the  mortality  account  of  appendi- 
citis by  his  diagnosis,  which  was  defined  at,  or  rather 
by  the  operation.  Suppose  such  a  patient  had  died 
without  being  subjected  to  operation;  the  diagnosis  of 
appendicitis  would  probably  not  have  been  made  at 
all.  It  is  a  fact  greatly  to  be  deplored  that  in  this 
country  the  permission  of  an  autopsy  is  granted  but 
exceptionally  by  the  relatives  of  the  deceased.  Thus 
it  appears  no  more  than  natural  that  the  case  should 
be  put  in  the  column  of  peritonitis  instead  of  bur- 
dening internal  medicine  as  a  fatal  case  of  appendi- 
citis. 

To  refer  to  Case  VI,  in  opening  the  peritonaeum  the 
conviction  could  not  be  suppressed  that  there  was  no 
hope.  Up  to  that  date  I  did  not  see  a  single  case  recover 
in  which  the  presence  of  serum  of  foul  odor  was  noted 
in  connection  with  the  absence  of  protecting  adhesions. 
Thus  I  am  inclined  to  regard  such  occurrences  as  a  kind 
of  criterion  for  further  revelations  in  the  peritoneal 
cavity.    It  seems  to  me  as  if  there  is  a  particularly  high 


IS   APPENDICITIS   A   SURGICAL   DISEASE?  87 

virulence,  which  manifests  itself  partially  by  this  macro- 
scopical  state. 

Were  aspiration  undertaken  in  such  a  case,  it  might 
be  that  before  operating  a  conclusion  might  be  drawn 
from  the  aspirated  serum  to  the  extreme  gravity  of  the 
case.  But  such  cases  take  such  a  rapid  course  that 
there  is  no  time  for  bacteriological  investigation.  Still, 
conclusions  should  be  drawn  from  the  direct  macro- 
scopical  state  as  to  the  dignity  of  the  toxon.  There  is 
only  one  drawback  ag,ainst  aspiration — namely,  the  pos- 
sibility of  further  inoculation  with  the  tip  of  the  needle, 
which  should  not  be  underestimated,  as  it  can  not  at  all 
be  compared  with  the  aspiration  of  an  empyema  or  simi- 
lar condition.  An  exploratory  incision  in  the  appen- 
dicular region  is  much  less  apt  to  spread  infection  than 
aspiration. 

Eegarding  further  dates  and  reports,  considering  the 
difficulties  to  find  an  adequate  clinical  expression  for  the 
grave  anatomical  lesions,  I  refer  to  my  previous  publi- 
cations on  this  subject — viz.,  On  Some  Difficulties  in 
Eeference  to  the  Early  Surgical  Treatment  of  Appendi- 
citis.* I  may  be  permitted  to  add  that  the  experience 
gained  since  these  articles  were  published  has  only 
corroborated  my  views  about  the  unreliability  of  the 
symptoms.  \ 

Most  cases  of  appendicitis  do  not  come  under  the 
observation  of  the  surgeon  during  the  first  forty-eight 
hours.  Procrastination  to  the  utmost  limit  before  the 
surgeon  with  all  his  terrors  is  called  upon  is  the  too 

*  Journal  of  fhe  American  Medical  Associatio7i,  December  28,  1896, 
and  Zur  Therapie,  insbesondere  dem  Werthe  der  Friihoperation  bei  der 
Entziindung  des  Processus  vermiformis,  Berliner  klinische  Wochenschrift, 
1896.  Nos.  37  and  38 


38  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

frequent  practice.  And  it  is  not  only  the  layman; 
no,  sometimes  it  is  a  hypersesthetically  disposed  colleague 
who  dreads  the  sight  of  steel  more  than  the  abominable 
appearance  of  a  bloody  tinged  intestine  bathed  in  foetid 
secretion.  This  horrid  intra-abdominal  picture,  of 
course,  is  veiled  from  his  eyes,  and  therefore  even  from 
his  imagination;  so  that  he  can  give  no  attention  to  it. 
How  often  have  I  thought  of  the  simple  words  of  the 
peerless  Henoch,  which  he  spoke  in  reference  to  the 
treatment  of  dysentery :  "  Whoever  has  seen  on  the  au- 
topsy table  the  immense  destruction  which  the  dysen- 
teric ulcers  cause  will  realize  why  so  often  our  whole 
therapy  sinks  into  nothingness."  Furthermore,  it  is 
to  be  remembered  that  from  a  pyappendix  sometimes 
emanates  a  subphrenic  abscess.  Cases  of  this  sort  are 
described  in  my  publication  on  subphrenic  abscess 
{Medical  Record,  February  15,  1896,  and  Langenbeek's 
Archiv,  Bd.  lii,  Heft  3). 

Abscesses  in  the  liver,  the  pleura,  the  brain,  may  also 
be  derived  from  appendicitis,  the  same  as  pyaemia  and 
some  lung  affections,  which  figure  as  causes  of  death  per 
se,  while,  in  fact,  appendicitis  should  be  registered  as 
such.  So  the  statistics  on  appendicitis,  as  they  are 
offered  nowadays,  can  not  be  regarded  as  other  than 
most  unreliable.  Only  tbe  most  careful  criticism  of  the 
cases  and  their  further  observation  after  a  so-called  well- 
overcome  attack  can  do  justice  to  the  surgeon. 

The  following  resume  may  now  be  made: 

1.  The  fate  of  patients  operated  upon  unsuccessfully 
by  the  surgeon  on  account  of  extremely  high  virulence 
or  undue  procrastination  is  sealed  beforehand. 

2.  The  patients  who  were  "  cured  "  under  medical 
treatment  would  also  have  recovered  had  they  submitted 


IS   APPENDICITIS  A   SURGICAL   DISEASE?  39 

to  operation.  For  the  small  number  of  deaths  after 
operation,  of  which  reports  are  given  once  in  a  while^ 
rather  the  surgical  novice  than  surgery  itself  is  respon- 
sible. 

3.  Eegarding  the  practice  of  delaying,  even  among 
most  of  those  who  advocate  surgical  interference,  to  rec- 
ommend operation  until  abscess  or  gangrene  is  demon- 
strated, it  must  be  realized  that  with  few  exceptions  all 
such  cases  would  finally  have  proved  fatal  under  the 
pursuance  of  medical  treatment. 

According  to  the  calculation  of  some  of  the  most 
eminent  surgeons  in  the  country,  there  are  about  five 
thousand  annual  deaths  from  appendicitis  in  the  United 
States  alone  which  could  have  been  prevented  by  early 
operation;  and  this  enormous  number  does  not  seem 
to  me  to  be  exaggerated.  We  thus  arrive  at  entirely  dif- 
ferent conclusions  from  those  drawn  from  many  inter- 
nal statistics  which  were  collected  bona  fide.  I  trust 
that  I  do  not  exaggerate  if  I  calculate  that  the  per- 
centage of  the  fatal  cases,  treated  expectantly  or  inter- 
nally, if  followed  up  ad  ultimum,  is  about  thirty.  This 
percentage  could  be  forced  down  to  ten,  or  even  to  five, 
if  the  custom  was  adopted  of  operating  early.  Is  it  not 
strange  that  of  all  the  patients  whom  I  have  operated 
upon  as  early  as  twelve  hours  after  the  onset  of  the 
attack,  none  have  died?  Unfortunately,  this  chance 
was  given  to  me  but  twenty-seven  times,  while  among 
those  of  my  patients  on  whom  I  operated  forty-eight 
hours  after  the  onset  there  is  a  mortality  of  twenty-four 
per  cent.  Why  do  the  internists  not  take  to  heart  the  ex- 
cellent words  of  Striimpell,  "  Better  too  early  than  too 
late."  Such  golden  words,  coming  from  a  distinguished 
internist,  do  more  for  the  popularization  of  the  surgical 


40  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

standpoint  than  all  efforts  of  the  surgeons  themselves; 
just  as  it  was  only  after  rib  resection  in  pyothorax  was 
indorsed  by  so  popular  a  man  as  Gerhardt  that  this 
operation  was  fully  recognized  by  the  family  physician. 

There  are  yet  to  be  considered  those  cases  of  appen- 
dicitis which  are  sent  to  the  hospital  under  the  diag- 
nosis of  internal  obstruction,  ileus,  etc.,  from  the  stand- 
point of  euthanasia.  Such  cases  being  far  advanced, 
differentiation  is  almost  impossible  without  operation. 

But  there  are  still  a  number  of  other  diagnostic 
errors  which  are  made  by  the  most  experienced  internists 
and  surgeons,  and  wbich  are  also  cleared  up  by  the 
operation  only. 

Empyema  of  the  gall  bladder,  for  instance,  is  a  fre- 
quent source  of  such  error.  A  striking  case  of  this  kind 
was  published  by  me  in  tlie  New  York  Medical  Journal, 
May  8,  1897.  (Compare  also  Centralblatt  fiir  Chirur- 
gie,  1897,  Ko.  42.) 

The  character  of  the  pain  is  regarded  as  one  of  the 
most  valuable  points  of  distinction  in  this  connec- 
tion. In  appendicitis  the  pain  will  often  be  localized 
around  the  umbilicus  and  epigastrium  to  establish  itself 
at  last  at  the  right  iliac  fossa,  while  in  cholelithiasis 
the  pain  remains  fixed  in  the  epigastrium  and  radiates 
at  the  same  time  toward  the  scapula.  Thus  the  point 
which  is  found  sensitive  on  palpation  would  correspond 
to  the  respective  regions  where  the  anatomical  change 
has  taken  place.  But  to  this  reflection  the  objection 
has  to  be  raised  that  the  subjective  localization  of  pain 
and  the  localization  of  the  anatomical  lesion  do  not 
always  correspond,  as  it  has  often  been  proved  in  simi- 
lar clinical  observations  which  were  followed  by  opera- 
tion and  revealed  the  pathological  derangement  at  a 


IS   APPENDICITIS   A   SURGICAL   DISEASE?  41 

distance  from  the  painful  region.  Considering  the  pain 
as  trustworthy,  it  must  be  remembered,  as  explained 
above,  how  ditferent  the  situation  of  the  appendix  is. 
It  is  found  far  down  in  the  true  pelvis  and  so  high  up 
that  in  an  inflamed  state  it  can  well  be  taken  for  a 
deeply  situated  gall  bladder,  the  latter  possibility  not 
being  so  very  rare  (compare  case  mentioned  above) 
that,  on  the  other  hand,  a  diseased  gall  bladder  could 
not  be  taken  for  a  thickened  appendix.  Adding  to  this 
the  fact  that  in  cholelithiases  icterus  is  more  frequently 
absent  than  present,  we  have  to  confess  that  in  the  ma- 
jority of  cases  we  have  to  relinquish  this  symptom,  which 
otherwise  is  of  such  immense  value  for  the  distinc- 
tion. 

The  type  of  the  vomiting  is  also  unreliable.  It  is 
regarded,  as  a  rule,  that  in  the  early  stage  of  appendicitis 
there  are  vomiting  attacks,  which  decrease  again  after 
a  while  and  later  on  increase  again,  while  in  gall-stone 
colic  there  is  continuous  and  frequent  vomiting.  Taking 
it  for  granted  that  this  is  so  in  the  majority  of  cases, 
it  can  not  be  denied  that  all  the  points  described  are 
not  determining,  and  the  ultimate  decision  in  such 
cases  will  only  be  reached  by  opening  the  abdomen. 

Pyosalpinx  is  also  sometimes  confounded  with  appen- 
dicitis. As  both  affections  indicate  laparotomy,  a  diag- 
nostic confusion  is  fortunately  not  of  great  practical 
significance.  There  is,  however,  a  difference  of  opinion 
as  to  whether  such  confusion  is  excusable  or  not.  Some 
say  that  nothing  is  easier  than  to  ascertain  the  presence 
of  a  swelling  situated  laterally  from  the  fornix  by 
bimanual  palpation.  Such  swelling  in  connection  with 
the  immobility  of  the  uterus  and  a  history  of  disturb- 
ances in  the  sexual  sphere  could  only  be  interpreted  as 


42  I'S   APPENDICITIS   A   SURGICAL   DISEASE? 

pyosalpinx.  Reliable  differential  conclusions  could  also 
be  drawn  froiu  the  character  of  the  temperature  as  well 
as  from  that  of  the  pains  and  their  radiation.  I  do  not 
hesitate  to  confess  that  this  error  has  happened  to  me 
twice,  when  I  have  been  unable  to  palpate  the  pyosalpinx 
even  after  an  anaesthetic  was  administered,  the  uterus 
having  been  slightly  movable  and  the  annexa  having 
appeared  to  be  normal.  The  explanation  was  that  the 
tumor  had  been  pushed  upward. 

On  the  other  hand,  it  can  easily  be  conceived  that 
in  a  case  where  the  appendix  reaches  far  down  a  pyo- 
salpinx is  diagnosticated  and  a  pyappendix  is  found  at 
the  operation.  And  it  also  happened  to  me  several  times 
that  I  was  asked  to  perform  an  operation  for  appendi- 
citis where  salpingitis  could  well  be  distinguished  with- 
out performing  an  abdominal  section.  (Compare  cases 
in  my  article  on  Appendicitis,  Berliner  Minische  Wo- 
chenschrift,  189G,  No.  38.) 

In  five  laparotomies  performed  for  pyosalpinx  I  have 
found  the  appendix  adherent  to  the  tube  or  ovary. 
There  the  appendix  was  always  removed  also.  On  exam- 
ination, cicatricial  strictures  were  found  in  each  of  these 
appendices,  from  which  fact  it  can  certainly  be  assumed 
that  it  had  participated  in  the  inflammation  of  the 
annexa.  It  is  also  not  excluded  that  an  appendicitis 
had  been  the  original  cause  of  the  inflammation  of  the 
annexa. 

Three  times  I  have  found  tube,  ovary,  and  appendix 
glued  together  in  a  colloid  mass,  undoubtedly  the  late 
3onsequence  of  old  inflammatory  processes.  There  I  was 
compelled  to  remove  a  considerable  portion  of  the  much- 
thickened  peritongeum  in  order  to  be  able  to  proceed 
radically. 


IS   APPENDICITIS   A   SURGICAL   DISEASE/  43 

Case  VII. — In  the  case  of  a  •woman  of  fifty  years  of 
age  on  whom  I  performed  resection  for  intestinal  car- 
cinoma the  following  peculiar  condition  was  found 
(see  Fig.  8)  :  A  tumor  originating  from  the  caecum,  of 
the  size  of  a  man's  fist,  and  easily  palpated  from  with- 
out, reached  from  the  median  margin  of  the  caecum  to 
the  end  of  the  ileum.  Above  this  tumor  there  was  a 
dermoid  cyst  ( Cy. ) ,  a  little  larger  than  an  apple,  and  at- 
tached to  the  tubal  wall ;  it  adhered  tightly  to  the  peri- 
tonaeum above  and  toward  the  renal  region.  It  con- 
tained the  characteristic  pulpy  mass  and  hairs,  cartilage, 
and  teeth.  The  lower  end  of  the  appendix  as  well  as 
the  tube  on  the  opposite  surface  of  the  cyst,  as  is  evi- 
dent from  Fig.  8,  adheres  extensively  to  the  der- 
moid cyst.  (T  represents  the  fragment  of  the  tube  and 
A  the  fragment  of  the  ovary.)  By  performing  a 
circular  resection  I  succeeded  in  removing  the  different 

Oy  Ov.  Care. 

'     - 


A.  L'iecuin. 

Fig.  8. — Appeudis  adherent  to  dermoid  cvbt.  tuue,  and  ovary. 

masses  in  their  coherence,  as  illustrated  by  Fig.  8.  In 
this  case  strictures  could  be  demonstrated  in  the  appen- 
dix also.  Considering  the  adhesions,  it  could  safely  be 
assumed  that  inflammatory  processes  had  been  present 
in  and  around  the  appendix.  To  these  probably  could 
be  traced  the  attacks  of  pain  which  the  patient  suffered 
once  in  a  while,  and  which  had  urged  her  to  the  opera- 
tion.    During  an  attack  of  this  kind  the  picture  of  her 


44  IP   APPENDICITIS   A   SURGICAL   DISEASE? 

cgecal  tumor  would  have  been  veiled,  and  so  the  thought 
of  appendicitis  could  well  have  arisen.  The  carcinoma 
itself  did  not  seem  to  have  caused  any  direct  disturb- 
ances, the  tumor  neither  having  narrowed  the  intestinal 
lumen  nor  had  signs  of  breaking  down  manifested 
themselves.  It  may  further  deserve  mention  that,  in 
view  of  being  able  to  displace  the  carcinoma  upward 
and  backward,  and  also  considering  the  good  appearance 
of  the  patient,,  the  possibility  of  the  presence  of  a  float- 
ing kidney  had  been  borne  in  mind. 

In  this  connection  it  should  be  remembered  that 
periodical  hydronephrosis,  caused  by  a  right  floating 
kidney,  which  may  exist  together  with  fever,  vomiting, 
and  pain  in  the  right  side,  could  give  rise  to  confusion 
with  appendicitis.  In  comparing  with  this  case  the 
views  of  Osier,*  I  think  that  the  mobility  of  the  tumor 
should  decide  the  question  in  favor  of  the  affection  of 
the  kidney. 

I  have  twice  been  guilty  of  a  confusion  with  a  right- 
sided  hsematosalpinx.  In  both  cases  the  disease  had 
begun  with  sudden  pain  in  the  side  and  with  mod- 
erate fever  and  vomiting  in  women  of  middle  age.  Both 
patients  recovered  and  have  certainly  not  noticed  any 
disadvantage  from  the  wrong  diagnosis. 

Extra-uterine  pregnancy  also  presents  itself  some- 
times, and,  after  peritonitis  has  manifested  itself,  makes 
the  meteorism  answer  to  the  question  of  inceptive  causes 
just  as  difficult  as  in  the  diseases  of  the  gall  bladder,  de- 
scribed above,  in  which  laparotomy  had  to  give  the  last 
word  of  explanation.  In  extra-uterine  pregnancy  the 
absence  of  menstruation,  in  connection  with  the  general 
symptoms  of  pregnancy,  the  bloody  vaginal  secretion, 

*  Principles  and  Practice  of  Medicine^  New  York,  1894,  p.  720. 


IS   APPEXDICITIS    A    SURGICAL    DISEASE?  45 

and  the  sensitive  tumor  in  the  fornix  have  to  be  mainly 
considered. 

In  general,  it  may  be  said  in  reference  to  the  dis- 
tinction between  appendicitis  and  diseases  of  the  an- 
nexa,  that  the  pain,  the  fever,  and  the  signs  of  peritonitic 
irritation  are  common  to  both,  but  that  in  the  latter  the 
progressive  tendency  of  extension  to  the  peritonaeum  is 
usually  lacking.  Thus  the  consensus  of  symptoms  in  dis- 
eases of  the  annexa  is  not  so  grave.  But  we  must  not  for- 
get that  sometimes,  as  already  said,  in  the  early  stage  of 
even  the  gravest  forms  of  appendicitis  there  are  no  reli- 
able signs  of  peritonitic  irritation.  For  the  disease 
of  the  annexa  the  gonococcus  is  mainly  responsible. 
The  gonococcus  is  a  bacterium  of  comparatively  low 
virulence.  This  becomes  evident  by  the  fact  that  gono- 
coccus pus,  finding  its  way  into  the  peritoneal  cavity, 
fails  to  produce  general  infection.  This  explains  why 
the  peritonitis,  caused  by  it,  generally  takes  a  favorable 
course.  If,  during  a  laparotomy  performed  for  pyo- 
salpinx,  the  misfortune  of  the  bursting  of  the  pus  sac 
happens,  so  that  pus  is  freely  discharged  into  the  peri- 
toneal cavity,  it  can  be  positively  ascertained  by  micro- 
scopical examination  in  a  few  minutes  whether  there  is 
gonococcus  or  streptococcus  or  staphylococcus  pus. 
(See  my  Manual  of  the  Modern  Theory  and  Tech- 
nique of  Surgical  Asepsis.  Saunders,  Philadelphia, 
1895.)  If  the  innocuous  gonococcus  diplococci  are 
found,  the  abdominal  cavity  may  safely  be  closed,  while 
in  the  latter  case  the  iodoform-gauze  tampon  is  to  be 
preferred. 

But  all  these  points  are  of  only  a  general  nature 
and  in  a  special  case  appearances  are  often  deceitful. 
It  is  also  to  be  considered  that  the  proof  of  benignity 


40  IS    ArPENDICITIS    A    ISURGICAL    DISEASE? 

is  often  furnished  only  after  the  process  has  taken  its 
course.  But  in  appendicitis  there  is  no  time  for  de- 
lay. Immediate  action  is  required  here;  the  patient 
not  profiting  after  the  lapse  of  a  few  days,  we  find  that 
there  is  no  hope  for  him  any  more.  Had  we  given 
him  the  practical  benefit  of  our  diagnostic  doubt  in  time, 
he  would  probably  have  been  saved  by  an  operation. 

As  said  above,  the  surgeon  is  not  infrequently  re- 
quested to  operate  for  alleged  internal  ohsti-uction,  for 
invagination,  intussusception,  volvulus,  or  for  adhesions 
of  inflammatory  or  congenital  origin,  in  which  the  in- 
testine is  caught  as  in  a  mouse-trap.  In  such  cases 
appendicitis  is  often  found.  Considering  the  great  sim- 
ilarity of  the  symptoms — viz.,  the  suddenness  of  the  at- 
tack and  of  the  pain,  the  vomiting,  and  the  subsequent 
peritonitis — the  confusion  is  obvious.  Here  it  must 
also  be  considered  that  in  internal  obstruction  the 
pain  concentrates  nearly  never  to  the  right  iliac  fossa, 
but  more  or  less  to  the  region  from  which  the  lesion  in 
question  itself  originated.  Furthermore,  it  should  be 
borne  in  mind  that  in  these  cases  the  vomiting  is  nearly 
constant  from  the  early  stage  on,  and  soon  assumes  a 
'fasculent  character,  .which  hardly  ever  happens  at  the 
early  stage  of  any  type  of  appendicitis.  Meteorism  also 
supervenes  only  late  in  appendicitis. 

In  intussusception,  a  painless  tumor  can  usually  be 
palpated.    Fever  is  generally  absent. 

In  volvulus,  digital  exploration  by  the  rectum  often 
gives  the  desired  information. 

In  mouse-trap  eases  there  is  generally  a  history  of  a 
preceding  peritonitis. 

The  difficulty  of  distinguishing  between  internal  ob- 
struction, gallstone  ileus,  and  appendicitis  was  illus- 


IS   APPENDICITIS   A   SURGICAL   DISEASE?  4.7 

trated  b}'  me  in  a  fatal  case,  (l(>scribcd  in  tlic  New- 
YorTcer  medicinische  Wochenschrift,  February  issue, 
1897,  p.  113. 

Sometimes,  also,  it  is  difficult  to  differentiate  be- 
tween appendicitis,  renal  and  gallstone  colic.  In  renal 
colic  it  is  important  to  know  that  the  pain  on  pressure 
is  mainly  limited  to  the  lumbar  region,  there  is  hardly 
ever  any  vomiting,  and  the  pain  gravitates  toward  the 
scrotal  and  rectal  region.  Vesical  tenesmus  and  hsema- 
turia  are  also  frequently  present. 

Ureteritis  may  also  be  confounded  with  appendicitis, 
especially  if  it  becomes  combined  with  cystitis  and  ne- 
phrolithiasis or  tuberculous  kidney.  The  presence  of 
blood  and  pus  in  the  urine  and  the  chronic  course 
should,  however,  be  conclusive  in  favor  of  ureteritis. 
My  experience  in  a  recent  case  of  nephrolithiasis,  which 
caused  ureteritis  shows,  however,  how  these  symptoms 
may  be  veiled. 

Case  VIII. — A  well-built  man,  thirty-five  years  of 
age,  who  had  always  been  well  until  about  a  year  ago, 
began  to  suffer  slightly  from  occasional  digestive  dis- 
turbances. On  October  1,  1898,  while  at  work,  he  noticed 
a  pain  of  moderate  intensity  in  the  right  iliac  fossa. 
AA^hen,  a  few  hours  later,  nausea  and  fever  set  in,  medi- 
cal treatment  was  obtained,  which,  so  far  as  could  be 
ascertained,  was  of  a  palliative  character.  On  the 
following  day  the  pain  and  nausea  disappeared  and  on 
October  3d  the  patient  resumed  work.  On  the  10th, 
after  having  passed  a  whole  week  without  discomfort,  he 
was  suddenly  attacked  with  intense  pain  in  the  same  re- 
gion. Under  the  administration  of  opium  and  the  use 
of  an  ice-bag  he  was  relieved  again  for  a  short  time, 
until,  on  the  11th,  the  symptoms  assumed  a  grave  char- 
acter. The  presence  of  a  tumefaction  was  discovered 
then  by  the  attending  physicians,  and  the  diagnosis  of 
appendicitis  made. 


-l-S  1«   APPEiNLKJlTlS   A   SURGICAL   DISEASE? 

On  the  14th,  when  the  patient  was  referred  to  St. 
Mark's  Hospital  for  operation,  the  following  state  was 
found:  The  emaciated  patient's  general  condition  made 
a  grave  impression.  Little  pain  was  complained  of.  Its 
character  was  hy  no  means  colicky,  and  it  radiated  some- 
what toward  the  umhilicus.  This  was  not  regarded  as  a 
pathognomonic  symptom,  since  the  absence  of  intense 
pain  could  be  exjjlained  by  the  narcotizing  influence  of 
the  toxines  jjresent.  The  bowels  were  constipated,  but 
the  passage  of  the  urine  was  normal.  Vomiting  was 
moderately  frequent.  The  pulse  was  130  and  feeble;  the 
temperature  was  101.2°  F. ;  and  the  respirations  were 
36.  The  abdomen  was  distended  and  slightly  painful  to 
the  touch.  In  the  right  iliac  fossa  tumefaction  and 
corresponding  dullness  were  found,  which  filled  the  iliac 
fossa  and  extended  anteriorly  to  the  mamillary  line. 
The  lumbar  region  showed  nothing  particular.  Exami- 
nation of  the  highly  saturated  urine  showed  nothing  ab- 
normal; especially  were  no  blood  casts  or  pus  detected. 

It  is  obvious  that,  in  view  of  the  presence  of  these 
symptoms,  so  characteristic  of  appendicitis,  the  diag- 
nosis was  positive.  The  operation  was  performed  on  the 
same  day,  after  saline  infusions  had  been  liberally  ad- 
ministered. The  incision  was  made  in  the  symphy- 
sis-rib  line.  When  the  peritonaeum  was  divided,  slightly 
odorous  pus  of  thick  consistence  and  gray-yellowish 
color  was  discharged.  Now  a  large  cavity  could  be  in- 
spected, the  median  wall  of  which  was  formed  by  the 
caecum,  to  which  a  normal-appearing  appendix  was 
attached  by  loose  adhesions.  In  the  bottom  of  the  cavity 
a  mass  of  necrotic  tissue  was  found  in  which  a  hard 
stone  of  the  size  of  a  large  filbert  was  discovered.  Its 
shape  was  elliptic  and  its  surface  granular.  Examina- 
tion showed  it  to  consist  of  a  nucleus  of  uric  acid  with 
oxalate  layers  around  it  and  a  superficial  coat  of  earthy 
phosphates.  The  situation  of  the  ureter  could  not  be 
made  out  distinctly  among  the  detritus.  Examination 
of  the  pus  revealed  nothing  particular.  The  cavity  was 
drained  with  iodoform  gauze.     Recovery  was  uninter- 


IS   APPENDICITIS   A   SURGICAL   DISEASE  V  4,9 

rupted,  and  the  patient  was  discharged  from  the  hos- 
pital a  month  after  the  operation.  No  urine  ever  es- 
caped through  the  wound. 

It  seems  to  me  that  the  calcuhis  had  found  its 
way  from  the  renal  pelvis  into  the  right  ureter,  where, 
on  account  of  its  large  size,  it  was  arrested.  There  it 
caused  considerable  irritation  and  inflammatory  changes, 
producing  the  formation  of  adhesions  in  which  the  cal- 
culus became  impacted.  This  happened  probably  at  the 
time  the  patient  noticed  the  first  pains,  on  October  1st. 
A  few  days  later,  probably  synchronously  with  the 
second  attack,  perforation  with  abscess-formation  took 
place,  the  adhesions  then  being  so  dense  that  they  pro- 
tected the  ureteral  perforation,  thus  preventing  the 
escape  of  urine  from  there. 

In  regard  to  the  absence  of  hsematuria,  the  possi- 
bility should  not  be  excluded  that  during  the  first  epoch 
it  might  have  been  present  unnoticed.  During  the 
second  attack  it  was  certainly  absent.  The  normal  pass- 
ing of  the  urine  and  the  absence  of  real  paroxysms  of 
renal  colic  are  most  remarkable  in  this  case.  Especially 
in  septic  cases  the  signs  of  nephritis  are  often  found  if 
the  lu'ine  is  carefully  examined.  Pus  in  the  urine  was 
observed  by  me  seven  times,  undoubtedly  the  conse- 
quence of  septic  absorption.  Only  three  of  these  cases 
recovered. 

How  coxitis  can  be  taken  for  appendicitis  has  been 
explained  above.  If  there  is  any  doubt,  the  Rontgen 
rays  will  always  throw  light. 

There  are  reports  on  typhoid  fever  in  the  first  week, 

when  moderate  fever,  slight  pain  in  the  right  iliac  fossa, 

and  meteorism  were  present,  having  been  confounded 

with  appendicitis.    But  the  history,  the  general  charac- 

4 


50  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

ter  of  typhoid  fever,  the  typical  temperature,  should 
permit  of  no  doubt.  Eegarding  perforation  of  a  typhoid 
ulcer,  it  can  be  maintained  that  the  symptoms  of  a  per- 
foration peritonitis  are  similar  to  those  produced  by  a 
perforative  appendicitis.  But  such  an  event  never  hap- 
pens before  the  third  week  in  typhoid  fever,  so  that  from 
the  further  course  conclusions  can  be  drawn  from  this 
fact. 

Since  it  became  known  that  with  few  exceptions  all 
the  forms  of  inflammation,  vaguely  termed  typhlitis, 
perityphlitis  and  paratyphlitis,  were  identical  with  the 
different  types  of  appendicitis,  the  impression  has  pre- 
vailed among  some  ultra-radically  inclined  colleagues 
that  typhlitis  has  gone  out  of  fashion  entirely.  But  that 
there  are  real  cases  of  stercoral  typhlitis  can  not  be 
doubted,  the  rarity  of  the  cases  being  of  course  admitted. 
At  the  early  stage  the  diagnosis  is  difficult,  since  the 
symptoms  are  identical  with  those  of  appendicitis.  The 
only  distinguishing  diagnostic  factor  would  be  furnished 
by  the  doughy  consistence  of  the  tumor.  Shrady  *  has 
sometimes  been  able  to  produce  indentation,  which  phe- 
nomenon can  be  plausibly  explained  from  the  faecal  com- 
position of  the  contents  of  the  tumor.  They  should, 
of  course,  not  be  confounded  with  cases  of  simple  co- 
prostasis,  as  happens  frequently.  That  such  cases  of 
coprostasis  are  always  easily  cured,  be  they  treated  under 
their  proper  name  or  under  the  false  diagnosis  of  appen- 
dicitis, by  the  omnipotent  laxative,  does  not  need  fur- 
ther argument. 

A  most  remarkable  case  which  had  been  operated 
upon  for  appendicitis  originally,  and  in  which  I  found 

*  Medical  Record^  January  6,  1897. 


IS  APPENDICITIS   A    SURGICAL   DISEASE?  51 

an  intact  appendix  by  performing  laparotomy  later,  is 
the  following: 

Case  IX. — A  strong  man  of  forty  years  of  age  fell 
ill  on  January  15,  1896,  with  intense  pain  in  the 
region  of  the  umbilicus  and  of  the  right  iliac  fossa. 
Nausea  and  fever  were  also  present.  In  spite  of  the 
gravity  of  the  symptoms  the  patient  walked  about  until 
January  29th  without  consulting  a  physician.  In  a 
septic  condition  he  was  then  admitted  to  St.  llark's 
Hospital.  There  a  small,  frequent  pulse,  high  tempera- 
ture, tumefaction,  and  a  corresponding  dullness  in  the 
right  iliac  fossa  were  noted.  The  diagnosis  was  appen- 
dicitis perforativa.  The  operation,  which  was  per- 
formed at  once,  revealed  partial  gangrene  of  the  caecum. 
There  was  grayish-yellow  pus  of  an  offensive  odor,  but 
without  a  serous  admixture.  The  appendix  was  not 
found.  After  the  operation  the  patient  recovered  some- 
what, but  soon  fell  into  a  state  of  somnolence.  The 
temperature  wavered  constantly,  and  the  pulse  re- 
mained between  120  and  150.  Repeatedly  abscesses, 
which  formed  near  the  caecum  between  intestinal  loops, 
were  opened.  Then  there  was  always  slight  temporary 
improvement,  soon  followed  again  by  the  recurrence  of 
septic  symptoms,  so  that  we  gave  the  patient  up  at  last. 
In  the  meanwhile  an  ectropion  of  the  extent  of  the 
palm  of  the  hand  had  formed  (Fig.  9).  Eisking  a  last 
effort  under  ether  aneesthesia,  I,  in  exposing  the  upper 
wound  margin,  detected  a  small  abscess,  which  reached 
upward  to  the  liver.  After  having  discharged  the  ab- 
scess, the  presence  of  which  had  not  at  all  been  sus- 
pected by  me,  the  patient  recovered  rapidly,  so  that  I 
could  proceed  to  the  closure  of  the  enormous  ectropion 
on  March  20th.  After  having  prepared  the  patient 
thoroughly  for  several  days,  and  after  having  packed 
the  afferent  and  deferent  ostia  prophylactically,  I  sev- 
ered the  intestine  extensively  from  the  adhesions,  this 
being  particularly  difficult  posteriorly.  The  freshened 
intestinal  wound  margins  were  coaptated  minutely  and 


52  I«   APPENDICITIS  A   SURGICAL   DISEASE? 

sewed  up  continuously  after  tlio  Lembert-Czerny  meth- 
od. There  was  perfect  union,  which  seems  to  be  mainly 
due  to  the  most  extensive  separation  of  the  adhesions. 
Many  surgeons  warn  us  against  resection,  as  in  most 
eases  a  little,  promising  procedure,  and  recommend  en- 
tero-anastomosis  instead. 

The  patient  had  defsecated  through  his  abdominal 
opening  ever  since  the  operation  on  January  29th.     Af- 


FiG.  9. — Intestinal  ectropion  after  gangrenous  typhlitis. 

ter  the  enteroplasty  he  defecated  by  the  rectum.  Only 
once,  ten  days  after  the  last  operation,  transitorily  faeces 
were  found  in  the  wound.  On  the  following  day  per- 
fect obliteration  had  taken  place  and  the  patient  enjoys 
the  best  of  health  ever  since.  After  the  separation  of 
the  intestine  was  perfected,  an  intact  appendix  was  dis- 


IS   APPENDICITIS  A   SURGICAL   DISEASE?  53 

covered  slightly  adherent  to  the  peritonaeum.  Examina- 
tion showed  the  mucosa  to  be  normal.  Therefore  it  may 
be  assumed  that  originally  the  gangrenous  process  was 
confined  to  the  wall  of  the  caecum. 

Among  other  confusions,  the  psoas  and  lumbar  ab- 
scesses may  yet  be  borne  in  mind,  the  recognition  of 
which  should  not  cause  much  difficulty. in  view  of  their 
slow  growth,  the  deformity,  the  absence  of  peritonitic 
manifestations  as  well  as  of  grave  initial  symptoms,  to- 
gether with  the  history. 

In  regard  to  the  diagnostic  difficulties  in  peritoneal 
tuberculosis,  I  refer  to  history  jSTo.  2. 

That  diseases  of  the  pancreas  have  been  mistaken 
for  appendicitis  can  be  appreciated  better  than  their  con- 
fusion with  malarial  disease,  influenza,  or  pneumonia. 

Arriving  now  at  the  salient  point  of  the  appendicitis 
question,  the  therapy,  we  still  hear  the  unceasing  battle 
cr}',  "  Here  opium,  here  scalpel !  "  If  we  realize  the  in- 
fectious and  progressive  nature  of  appendicitis,  as  I  tried 
to  emphasize  it  in  the  introduction  of  my  article,  we 
shall  not  expect  a  cure  from  internal  treatment;  while 
by  modern  surgical  technique  we  are  able  to  reach  the 
focus  of  disease  and  to  render  it  innocuous  at  its  early 
stage.  I  must  therefore  answer  the  question,  "  Is  appen- 
dicitis a  surgical  disease  ? "  in  the  clear  affirmative. 
This  does  not  mean. that  appendicitis  should  altogether 
be  turned  over  from  the  hands  of  the  internists  to  those 
of  the  surgeons.  There  is  no  fear  of  that,  because  the 
appendicitis  public  also  has  a  word  to  say  in  this  mat- 
ter. In  practice  a  case  of  appendicitis  never  goes  direct- 
ly to  the  surgeon,  since  the  patient  himself  never  makes 
the  diagnosis  appendicitis,  but  he  suffers  from  the  omi- 
nous pain,  which,  more  than  his  feelings  of  general  ma- 


54  If'   APPENDICITIS   A   SURGICAL   DISEASE? 

laise,  causes  him  to  see  his  family  physician.  What  he 
demands  from  him  first  is  that  he  should  cure  his  "  belly- 
ache." 

Now,  this  family  physician  should  realize  that  he  is 
confronted  with  a  disease  of  absolutely  surgical  char- 
acter, and  that,  unless  he  can  cure  it  surgically  him- 
self, he  should  immediately  call  in  the  aid  of  a  surgeon. 
In  this  manner  most  surgical  cases  do  not  drift  into  the 
hands  of  the  surgical  specialist,  but  nearly  always  into 
those  of  the  general  practitioners,  whose  greater  or  lesser 
skill  in  surgery  turns  the  scale,  whether  or  not  the  case 
really  requires  further  deliberation  with  a  surgeon. 

So  we  find  it  natural  that  in  fractures  the  family 
physician  is  called  in  first.  So  long  as  he  trusts  he  can 
master  the  case,  he  would  be  blamed  for  summoning  a 
surgeon.  But  there  would  be  much  more  reason  for 
blaming  him  if  he  did  not  fully  realize  that  he  had  to 
deal  with  a  strictly  surgical  disease,  which  he  must  treat 
after  true  surgical  principles.  Should  he  encounter  any 
difficulties  in  the  treatment  of  the  fracture,  there  is 
nearly  always  enough  time  to  take  a  surgical  specialist 
into  council  and  to  conduct  further  treatment  accord- 
ing to  his  advice.  But  in  appendicitis  success  is  mainly 
determined  by  immediate  interference,  and  the  right  to 
interfere  is  his  only  who  is  competent  to  execute  the 
cure  technically. 

That  there  is  plenty  of  space  for  cooperation  of  the 
family  physician,  who  is  conversant  with  a  great  many 
matters  which  the  surgeon  again  does  not  know,  and 
whose  knowledge  is  to  the  surgeon's  and  the  patient's 
greatest  advantage,  is  beyond  question. 

It  shall  not  be  denied  that  immobilization  of  the 
intestine  by  opium,   after  a   preceding  evacuation   of 


IS  APPENDICITIS   A   SURGICAL   DISEASE  V  55 

the  lower  intestinal  portion  by  an  enema,  will  pro- 
duce a  perfect  palliative  success  in  a  large  number  of 
cases  of  appendicitis.  But  a  real  cure  can  be  expected 
as  little  as  from  the  mere  adoption  of  the  splint  in 
phlegmon  of  the  hand.  The  administration  of  opium 
for  the  purpose  of  arresting  intestinal  peristalsis,  agree- 
able as  it  is  for  the  patient,  has  the  most  deplorable 
consequence  that  it  lulls  not  only  the  patient  but  also 
the  attending  physician  into  a  feeling  of  security,  from 
which  both  are  aroused  most  cruelly  by  the  early  appear- 
ance of  peritonitic  symptoms.  Therefore  the  adminis- 
tration of  opiates  should  be  advised  against  most  ener- 
getically before  a  distinct  diagnosis  is  arrived  at.  After 
the  diagnosis  is  made,  the  administration  of  opium  is 
rational,  even  if  immediately  afterward  the  operation  is 
performed. 

However  light  the  clinical  expression  of  appendi- 
citis may  be,  and  liow  much  it  may  appear  to  be  in  favor 
of  a  speedy  temporary  recovery,  the  operation  is  always 
justifiable.  As  the  strength  of  the  infection  can  never 
be  known  with  certainty  from  the  beginning,  it  appears 
to  be  wiser  to  take  each  appendicitis  seriously.  Among 
two  evils  the  smaller  should  be  chosen,  and  operation  is 
the  smaller  evil. 

The  assumption  of  a  simple  appendicitis  with  a 
tendency  to  spontaneous  resolution  is  mostly  made  by  a 
comparatively  untrained  observer. 

If  there  be  nothing  more  than  a  simple  appendi- 
citis, I  can  not  see  how  in  the  hands  of  an  aseptically 
trained  surgeon  life  should  be  jeopardized  by  simple 
appendectomy,  even  if  it  should  prove  to  have  been  un- 
necessary. But  if  there  is  perforation  or  gangrene  in 
the  nascent  stage,  the  early  operation  positively  saves 


56  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

the  life  of  the  patient,  who  otherwise  would  probably 
succumb  to  internal  or  expectant  treatment. 

Thus  at  the  early  stage  the  surgeon  is  the  boss,  so  to 
say,  while  in  the  late  stage  he  is  an  adventurer,  who  is 
successful,  yet  only  once  in  a  while,  under  extraordinary 
circumstances.  But  times  have  passed  when  celebrated 
surgeons  found  it  expedient  to  write  books  on  "  luck  in 
surgery." 

If  the  attending  physician  does  not  care  to  be  con- 
verted to  this  standpoint  he  should  at  least  regard  it  his 
duty  to  explain  the  nature  of  the  disease  to  his  patient, 
and  to  leave  it  to  him,  whether,  after  he  passed  his 
attack,  he  had  better  have  his  appendix  preserved 
in  the  alcohol  bottle  than  in  his  iliac  fossa,  where  it 
represents  an  explosive  stuff  which  may  lead  to  a  catas- 
trophe any  moment.  He  can  surely  depend  upon  en- 
countering a  second  or  third  attack  after  having  been 
through  one,  and  there  is  little  doubt  that  he  has  to  suc- 
cumb to  one  of  these  attacks  some  day. 

Considering  that  under  the  auspices  of  asepsis  the 
mortality  of  simple  appendectomy  is  nearly  nil,  every 
colleague  should  regard  it  his  duty,  no  matter  to  what 
colors  he  has  sworn,  at  least  to  communicate  these  facts 
to  his  patient.  Up  to  date  I  have  performed  simple 
appendectomy  seventy-four  times  without  a  single  death. 
I  know  that  there  are  several  surgeons  in  this  city 
who  could  report  a  much  larger  number  of  similar  cases 
with  the  same  gratifying  result. 

Even  extensive  adhesions  should  not  cause  disturb- 
ances in  the  course  of  the  wound  treatment.  And  these 
adhesions  are,  as  a  rule,  only  present  if  there  has  been 
more  than  one  attack,  as  after  one  attack  generally  only 
slight  adhesions  are  detected. 


IS   APPEiXDICITlS   A   SURGICAL   DISEASE?  57 

As  alluded  to  above  in  the  pathological  part  of  this 
article,  most  patients  who  have  gone  over  one  attack  of 
appendicitis  suffer  more  or  less  from  disturbances  of 
stomach  or  intestine,  which  becomes  worse  on  the  slight- 
est provocation.  The  fear  of  injuring  themselves  forces 
a  regimen  upon  them  which  impairs  their  nutrition  and 
becomes  unendurable  in  the  end.  Thus,  even  when 
well-marked  local  symptoms  fail  to  show  themselves,  a 
picture  similar  to  hypochondriasis  develops.  If  the 
appendix  is  removed  in  such  patients,  one  is  surprised 
to  see  how  at  one  swoop  all  these  symptoms  disappear, 
and  the  jDatient  becomes  an  entirely  new  man. 

In  drawing  conclusions  from  what  has  been  said  we 
may  condense  them  into  the  following  theses : 

1.  Appendicitis  is  a  surgical  disease  and  should  be 
treated  surgically  as  soon  as  the  diagnosis  is  made. 

2.  So  long  as  no  physician  is  able  to  ascertain  the 
grade  of  bacterial  virulence  at  its  early  stage,  the 
safest  therapy  consists  in  the  early  removal  of  the 
appendix. 

3.  If  the  patient  or  his  advisers  should  object  to 
operation,  the  expectant  immobilization  treatment 
should  be  instituted,  and,  after  the  attack  is  over,  the 
necessity  of  appendectomy  thereafter  should  be  made 
clear  to  the  patient.  ^ 

4.  Should  the  conditions  surrounding  the  patient 
be  of  an  extremely  unfavorable  nature,  should  no  com- 
petent surgeon  be  obtainable,  and  should  there  be  other 
difficulties,  the  risk  of  the  expectant  treatment  should 
be  preferred  to  that  of  a  badly  performed  operation  in 
an  acute  attack.  Then,  if  he  should  pass  over  the  attack, 
the  patient  should  submit  to  appendectomy  later. 

5.  Considering  that  the  mortality  of  simple  appen- 


58  IS   ArrENDICITIS   A    SUKGICAL   DISEASE? 

dectomy  is  almost  nil,  its  performance  should  be  urgent- 
ly recommended  to  the  patient  after  the  first  attack. 

I  well  realize  that  doing  this  will  often  cause  the 
greatest  difficulties  to  the  family  physician.  So  many 
prejudices,  so  many  family  considerations  obtrude  on 
him  that  he  will  often  fail  to  have  the  courage  to 
contend  with  the  whole  weight  of  his  personality  for 
these  theses,  although  he  is  convinced  of  their  scientific 
truth.  Nor  will  I  throw  a  stone  at  the  family  physician 
who,  jurans  in  verba  magistri,  intoxicates  himself  with 
the  sphere  music  of  internist  statistics,  and  shows  the 
surgeon,  who  advises  operation,  sneeringly  the  list  of 
dissuading  internists.  I  simply  deplore  things  as  they 
are,  and  add  my  share  to  the  better  appreciation  of  a 
disease  which,  to  its  full  extent,  is  recognized  by  none 
of  us  yet.  But  I  may  hope,  with  those  who  agree  to  my 
views,  that  the  day  will  come  when  its  surgical  prospec- 
tive will  be  everywhere  acknowledged. 

But  what  we  are  entitled  to  demand  imperatively 
from  every  one  who  undertakes  treating  appendicitis  is, 
that  he  learn  enough  of  the  pathology  of  the  appendix 
to  appreciate  from  the  beginning  the  risk  which  the  pa- 
tient runs  during  his  acute  attack,  and  that  information, 
should  be  given  accordingly.  Penzoldt  well  says  of 
appendicitis :  "  In  none  of  these  cases  can  a  gloomy 
sensation  of  gravest  responsibility  be  suppressed.  The 
physician  who  does  not  know  this  sensation  does  not 
know  the  nature  of  this  disease." 

The  technics  of  simple  appendectomy,  as  I  perform 
it  in  recent  years,  is  the  following : 

First  of  all,  I  make  it  a  principle  to  put  the  patient 
in  bed  for  at  least  two  days  and  to  give  him  only  fluid 
diet  during  this  period.    After  admission  to  the  hospital 


IS  APPENDICITIS   A   SURGICAL   DISEASE?  59 

he  first  takes  one  or  two  tablespoonf uls  of  castor  oil ;  on 
the  following  day,  and  on  the  morning  of  the  opera- 
tion, an  enema  is  applied.  For  thorough  prophylactic 
disinfection  the  iliac  and  pelvic  regions  are  shaved. 
While  a  warm  bath  is  taken,  a  rigid  scrubbing  with 
green  soap  is  done.  Then  a  poultice  of  green  soap  is 
applied  to  the  right  lower  abdomen,  which  remains  twen- 
ty-four hours.  I  regard  this  an  essential  factor  for  the 
disinfection  of  the  skin,  because  I  do  not  believe  that 
under  ordinary  circumstances  the  epidermis,  which  shel- 
ters a  multitude  of  pathogenic  bacteria,  can  be  ren- 
dered sterile  by  the  usual  methods  of  disinfection,  which 
generally  are  not  carried  out  for  more  than  from  ten  to 
fifteen  minutes.  A  period  of  twenty-four  hours  gives  the 
soap  a  chance  to  permeate  the  epidermis  thoroughly,  so 
that  scrubbing  on  the  following  day  is  much  more 
effective.  Sometimes,  indeed,  the  poultice  macerates 
the  .epidermis  so  that  it  can  be  wiped  off  easily.  Shortly 
before  the  operation  the  skin  is  scrubbed  with  gauze 
mops  dipped  in  alcohol,  the  use  of  which  is  more  im- 
portant than  that  of  any  antiseptic  drug,  as  it  dis- 
solves the  fat  of  the  skin.  Bacteria  so  long  as  they  are 
imbedded  in  fat  will  not  be  influenced  at  all  by  the 
strongest  antiseptic  medicament.  I  always  attempt  to 
have  the  protecting  sterile  napkins  as  i  near  the  wound 
margin  as  possible,  fastening  them  there  with  small 
miniature  forceps,  so  that  all  subsequent  manipulations, 
especially  ligation  and  suturing,  can  be  done  on  a  safe 
and  sterile  field.  I  have  repeatedly  seen  surgeons  who 
had  taken  minute  care  in  their  aseptic  preparations 
wallow  around  the  intestine  on  the  abdominal  skin  in 
the  roughest  manner  while  manipulating  it  after  it  was 
taken  from  the  abdominal  cavity. 


00  IS   AP1'E]^JD1C1TIS   A   SURGICAL    DISEASE? 

The  operator,  as  well  as  the  assistant  engaged  at 
the  wound,  and  the  one  who  hands  the  instruments,  wear 
sterilized  linen  gloves.  So  long  as  we  are  not  in  posses- 
sion of  an  absolutely  reliable  method  of  rendering  the 
hands  of  the  operator  indisputably  sterile,  they  should 
have  a  reliable  aseptic  protection,  even  though  this  may 
interfere  with  the  elegance  of  the  operation.  After  the 
abdomen  is  opened  the  gloves  might  be  taken  off  for  the 
minute  work  on  the  intestine.  In  pus  cases  they  may  be 
taken  off  after  the  abdomen  is  well  cleaned.  (On  the 
employment  of  gloves,  compare  the  writer's  manual  of 
the  theory  and  technics  of  surgical  asepsis,  Saunders, 
Philadelphia,   1895,  p.   94.) 

The  procedure  of  making  the  skin  incision  is  of 
greatest  importance.  After  having  experimented  with 
various  methods,  I  found  it  most  opportune  to  modify 
McBurney's  method  in  making  a  long  incision  in  the 
direction  of  the  fibres  of  the  external  oblique  muscle  in 
such  a  manner  that  its  centre  fell  into  the  middle  of  the 
line  drawn  from  the  symphysis  to  the  anterior  end 
of  the  eleventh  rib.  The  incision  begins  about  three 
fingers'  breadth  above  the  symphysis,  and  ends  in  the 
same  distance  from  the  anterior  end  of  the  eleventh 
rib  in  the  line  described  (Fig.  10).  Now  the  fatty 
superficial  fascia  and  the  fascia  of  the  external  oblique 
muscle  are  divided.  The  rectus  muscle  is  not  concerned, 
there  being  no  fear  of  injuring  its  sheath,  which  would 
cause  little,  yet  troublesome,  hemorrhage,  and  also  a 
series  of  disturbances  in  the  course  of  the  wound  treat- 
ment, inasmuch  as  the  wound  margins  could  only  with 
difficulty  be  approximated  to  each  other. 

Now  the  fibres  of  the  external  oblique  muscle  are 
carefully  separated,  which  can  be  done  easily  with  the 


IS   APPENDICITIS  A   SURGICAL   DISEASE? 


61 


handle  of  the  scalpel,  considering  that  the  direction  of 
the  incision  corresponds  to  that  of  the  muscular  fibres. 
If  the  margins  are  kept  asunder  by  broad  hooks,  it  is 
generally  possible  to  separate  the  underlying  fibres  of 
the  internal  oblique  and  of  the  transverse  muscle  blunt- 
ly in  the  same  manner— that  is,  corresponding  to  the 
direction  of  the  fibres.  The  centre  of  this  cross  inci- 
sion must  be  identical  with  the  one  of  the  oblique  lon- 


FiG.  10. — Direction  of  the  incision  in  appendectomy. 


gitudinal  incision.  It  is  true  that  there  is  a  longitudinal 
as  well  as  a  crossed  wound,  but  the  size  of  the  former, 
if  the  margins  be  kept  well  asunder,  permits  of  con- 
siderable distention  of  the  second  incision,  which,  in 
emergencies,  might  be  prolonged  to  the  sheath  of  the 
rectus  muscle  on  one  side  and  to  the  crista  ossis  ilei  on 
the  other. 

Nothing  but  the  fatty  subserous  stratum,  which  par- 
titions off  the  peritoneum,  now  remains ;   it  must  be 


62 


IS   APPENDICITIS  A   SURGICAL   DISEASE? 


pushed  out  of  the  way.  After  having  stopped  each  point 
of  hasmorrhage  thoroughly,  no  matter  how  scant  it  may 
be,  the  peritonaeum  is  lifted  by  a  small-toothed  forceps 
and  is  carefully  raised  at  its  most  elevated  point  just 
wide  enough  to  permit  the  insertion  of  a  grooved  di- 


FiG.  11. — Removal  of  the  appendix  after  securing  tlie  base  by  a  ligature. 


rector,  upon  which  the  further  division  of  the  perito- 
naeum is  completed.  Now  the  index  finger  is  introduced 
to  get  hold  of  the  appendix.  Sometimes  it  can  be  made 
to  slip  out  like  a  little  eel,  so  that  the  whole  operation  can 
at  once  be  finished  extra-abdominally.   But  in  the  major- 


IS   APPENDICITIS   A   SCRCxICAL   DISEASE?  63 

ity  of  cases  the  caput  coli  must  first  be  drawn  out;  and 
even  then  the  adhesions  formed  by  previous  inflamma- 
tory processes  tighten  it  to  such  an  extent  that  the 
abdominal  wound  must  be  enlarged  transversely.  But 
even  then  it  frequently  takes  some  time  until  the  appen- 
dix, which  has  undergone  pathological  changes,  can  be 
brought  into  view.  In  order  to  get  a  landmark  it  is  best 
to  secure  the  ascending  colon,  which  can  be  recognized 
by  the  longitudinal  direction  of  its  muscular  fibres.  By 
following  the  ascending  colon  downward  the  fundus  of 
the  appendix  is  reached  anteriorly.  If  there  be  no  adhe- 
sions of  any  account  the  appendix  is  removed  after  hav- 
ing ligated  its  mesenteriolum  in  three  or  more  portions 
(Fig.  11). 

For  this  purpose  I  use  the  formalin  catgut  exclu- 
sively, the  sterility  of  this  material,  after  it  is  boiled, 
being  indisputable.  After  squeezing  the  contents  of  the 
appendix  into  the  caecum,  the  fundus  of  the  appendix 
is  tied  with  a  catgut  ligature.  The  same  procedure  is 
repeated  about  half  a  centimetre  below  (compare  Fig. 
11).  Then  with  one  stroke  of  the  scissors  the  appendix 
is  severed  closely  above  the  lower  ligature.  By  previous- 
ly having  squeezed  out  the  contents  of  the  appendix  and 
by  tying  doubly  afterward,  the  exit  of  any  facal  matter  is 
prevented.  The  protruding  mucous  membrane  of  the 
appendix,  after  being  disinfected  with  a  strong  solution 
of  bichloride  of  mercury,  is  then  seized  with  an  artery 
forceps  and  pulled  out  as  far  as  possible.  Now  it  is 
cleanly  cut  off  with  the  scissors  (Fig.  13) .  There  is  then 
left  a  muscular  serous  flap,  which  can  easily  be  united 
by  three  Lembert  sutures  (Fig.  13).  x\fter  the  removal 
of  the  mucous  membrane  some  iodoform  powder  is 
dusted  over  the  remainder  of  the  mucous  membrane  in 


64 


IS   APPENDICITIS  A   SURGICAL   DISEASE? 


the  depth ;  but  dusting  the  little  wound  margins,  which 
are  to  be  united,  is  to  be  very  carefully  avoided.     All 


Fig.  li. — Removal  of  the  mucous  membrane. 


these  manipulations  take  place  after  the  neighboring  in- 
testines, particularly  the  area  situated  directly  below  the 
appendix,  are  protected  extensively  with  sterile  com- 
presses. 

In  some  cases  the  appendix  is  so  deeply  imbedded 
in  thick  adhesions  that  it  appears,  as  said  above,  like  a 
mummy  baked  into  lava.  Its  structure  is  then  so  much 
changed  that  it  can  only  be  identified  after  a  long  search. 
Then  it  is  recommendable  to  separate  the  appendix  at  its 
cascal  end  first,  so  that  the  colon  can  be  pushed  away 
from  the  operating  field,  after  which  removal  of  the 
appendix  can  be  done  much  easier.  It  has  happened  to 
me  repeatedly  to  have  to  proceed  step  by  step  by  mak- 
ing very  small  incisions  to  shell  out  the  appendix,  which 


IS   APPENDICITIS   A   SURGICAL   DISEASE?  65 

sometimes  reached  crosswise  up  to  the  spinal  column. 
After  its  removal  its  groovelike  bed  resembled  the 
emptied  husk  of  a  bean  pod. 

In  doubtful  cases  it  is  preferable  to  leave  a  serosa 
fragment  rather  than  to  extirpate  too  radically,  in  which 
cases  the  surface  bleeding  may  become  considerable. 

After  having  stopped  every  little  bleeding  point 
minutely,  whether  by  means  of  hot  compresses  or  with 
the  finest  formalin  catgut,  the  peritoneal  margins  can 
be  united  with  the  same  catgut.  Then  follows  the  trans- 
verse fossa.  The  transverse  and  the  external  oblique 
muscle  require  but  little  suturing,  as  they  approximate 
themselves  by  themselves  as  soon  as  the  tenacula  are 
withdrawn. 

Hernia  after  this  operation  is  an  impossible  sequel. 
It  can  occur  only  in  cases  where  the  great  extent  of 


Fig.  13. — Suturing  the  stump. 

adhesions  necessitates  enlarging  the  transverse  wound 
to  such  an  extent  that  the  sheath  of  the  rectus  muscle 
5 


06  IS  APPENDICITIS   A   SURGICAL   DISEASE? 

has  to  be  injured.  It  is,  of  course,  in  the  interest  of 
the  patient  to  enlarge  the  opening  at  the  expense  of  a 
possible  hernia  rather  than  to  restrict  the  liberty  of  in- 
tra-abdominal manipulations.  Still,  I  have  always  suc- 
ceeded so  far  in  removing  the  appendix  within  the  limits 
described  without  attacking  the  neighboring  tissues. 

The  technics  of  appendicotomy  {sit  venia  verho)  is 
the  same  in  principle,  be  there  an  acutely  inflamed,  a 
perforated,  or  a  gangrenous  appendix.  Virtually  the 
preparations  should  be  just  as  thorough  as  if  there  had 
to  be  done  a  simple  appendectomy  in  a  non-infected 
abdomen.  The  patient  can  not,  of  course,  spend  two 
days  in  making  preparation;  but  the  disinfecting  pro- 
cedures immediately  preceding  the  operation  should  be 
carried  out  with  great  strictness,  while  the  patient  is 
anaesthetized. 

From  the  time  of  the  consultation  up  to  the  time  of 
the  operation  at  least  two  hours  elapse,  during  which 
time  there  is  a  chance  to  scrub  the  abdomen  with  green 
soap,  and  alcohol  thereafter.  Up  to  the  time  when  the 
ansesthesia  is  complete  a  poultice  of  green  soap  or  forma- 
lin should  be  kept  on  the  abdomen. 

If  the  pulse  is  of  a  bad  quality,  a  subcutaneous 
saline  infusion  should  always  be  given.  I  am  accus- 
tomed to  administer  a  saline  infusion  shortly  before  each 
capital  operation  prophylactically  if  the  pulse  is  not  very 
good. 

The  direction  of  the  incision  is  also  the  same.  But  if 
palpation  or  percussion  indicates  the  presence  of  an 
exudate,  the  incision  must  be  made  as  lateral  as  possible. 
Generally  the  line  drawn  from  the  symphysis  up  to  the 
anterior  end  of  the  eleventh  rib  answers  best.  But  if  the 
exudate  be  situated  far  outward,  the  incision  may  be 


IS  APPENDICITIS   A   SURGICAL   DISEASE?  67 

made  nearer  to  the  spina  anteriora  superiora  ossis  ilei. 
It  may  easily  happen  that  in  incising  above  the  so-called 
McBurney's  point  the  partition  walls,  situated  toward 
the  median  line  and  formed  of  protecting  adhesions, 
should  be  cut.  This  deplorable  accident  has  happened 
twice  to  me.  Such  a  focus,  secluded  by  adhesions  from 
the  abdominal  cavity,  becomes,  in  fact,  extraperitoneal, 
and  its  opening  is  nearly  as  innocent  as  that  of  an 
abscess  situated  not  too  superficially  on  most  other  parts 
of  the  body. 

The  incision  should  not  begin  above  the  symphysis, 
as  in  simple  appendectomy,  but  partly  above  it,  as  it  is 
exceptional  that  the  lower  limits  of  the  abscess  can  not 
be  followed  down  to  the  true  pelvis. 

As  demonstrated  above,  the  formation  of  small  ab- 
scesses directly  above  Poupart's  ligament,  which  are 
often  only  demonstrated  by  percussion,  is  by  no  means 
of  rare  occurrence.  In  the  last  instance  one  may  be 
guided  as  to  the  preference  of  the  direction  of  the  in- 
cision by  the  result  of  the  palpation  or  percussion.  By 
all  means  the  principle  should  be  obeyed :  "  Better  too  far 
outward  than  inward." 

The  external  oblique  muscle  can  also  be  separated 
bluntly.  In  regard  to  the  fibres  of  the  internal  oblique 
and  the  transversalis,  which  run  crosswise,  it  is  not 
necessary  to  be  as  conservative  in  the  case  of  the  presence 
of  an  exudate  as  if  there  was  a  simple  appendectomy  to 
be  performed.  If  speed  is  required,  the  fibres  may  be 
divided  nearly  transversely — that  is,  directly  parallel  to 
the  skin  incision.  But  in  simple  appendicitis  or  pyap- 
pendix  the  blunt  method  always  holds  good. 

After  having  arrived  at  the  peritonaeum  the  way  is 
best  cleared,  if  there  be  an  exudate,  with  the  groove(i 


68  IS   APPENDICITIS  A   SURGICAL  DISEASE? 

director.  If  pus  appears  on  it,  a  small  forceps  is  pushed 
along  the  groove  of  the  instrument  and  the  opening  in 
there  gradually  dilated.  Frequently  the  dark-red  cae- 
cum, covered  with  fibrinous  flocks,  presses  forward,  so 
that  the  greatest  care  has  to  be  observed  not  to  injure 
it  with  a  cutting  instrument.  Therefore  it  is  urgently 
advisable  to  use  none  but  dull-pointed  scissors  or  scal- 
pels for  the  further  division  of  the  peritongeum. 

Now  careful  wiping  and  inspection  is  done.  Gener- 
ally, only  fresh  adhesions  are  found,  and  in  order  to 
approach  the  appendix,  tightly  bound  down,  they  have  to 
be  severed  first  by  moderate  pulling.  During  these  pro- 
cedures the  neighboring  organs  must  always  be  well  pro- 
tected by  gauze  mops  which  are  pushed  underneath. 

If  the  appendix  is  closely  attached  to  the  wall,  con- 
sisting of  protecting  adhesions,  it  is  preferable  to  leave 
it  there,  provided  it  can  not  be  removed  without  destroy- 
ing the  protecting  wall.  Then  an  iodoform  gauze  strip 
should  be  built  around  it  or  its  fragments,  which  can  be 
removed  safely  a  few  days  thereafter.  But  if  it  can  be 
shelled  out  without  such  difficulties,  it  should  be  done, 
and  the  tying  and  extirpation  should  be  performed  ac- 
cording to  the  methods  of  simple  appendectomy.  But 
every  possible  means  should  be  tried  before  making  the 
decision  to  leave  an  appendix,  degenerated  and  infected, 
in  the  abdomen.  It  often  happens  that  we  are  too 
conservative,  and  small  abscesses,  covered  by  the  im- 
bedded appendix,  are  overlooked,  so  that  the  patient 
may  still  die,  the  large  abscess  only  having  been  dis- 
charged and  one  or  more  little  foci  upholding  and 
spreading  the  infection. 

If  there  is  complete  gangrene,  the  appendix  can  not 
be  recognized  as  such  any  more.    There  its  grayish-black 


IS   APPENDICITIS  A   SURGICAL   DISEASE?  69 

fragment  must  be  removed  with  a  blunt  forceps.  Even 
the  slightest  pull  on  its  cffical  junction  may  cause  the 
discharge  of  fffical  contents,  and  it  is  therefore  of  the 
greatest  importance  to  push  gauze  compresses  without 
delay  underneath  the  endangered  area  just  as  soon  as  the 
appendix  comes  into  view.  Suturing  is  inadvisable; 
iodoform-gauze  packing  is  to  be  preferred,  after  having 
cleaned  the  abdominal  cavity  thoroughly.  Sometimes 
small  fffical  fistulge  form,  which  usually  close  spontane- 
ously. 

If  the  mucous  membrane  protrudes,  the  attempt  may 
be  made  to  cauterize  the  ectropion  by  Paquelin's  cautery. 
If  this  proves  ineffectual,  extensive  post-operative  means 
have  to  be  resorted  to  (compare  Case  VIII,  Fig.  9). 

In  gangrene,  however,  a  protecting  wall,  consisting 
of  adhesions,  is  hardly  ever  formed;  in  such  cases  we 
have  to  deal  with  peritonitis  rather  than  with  appendi- 
citis. Sometimes  it  fortunately  happens  that  the  adhe- 
sive peritonitis  agglutinates  the  intestinal  loops  adjoin- 
ing the  cascal  region,  so  that  really  extensive  perito- 
nitis is  confined  to  a  comparatively  circumscribed  area. 
This  rare  good  fortune  is  explained  by  the  careful  evac- 
uation of  pus  foci  by  the  guarded  boring  index  finger, 
and  furthermore  by  the  minute  wiping  off  of  all  fibrinous 
flocks.  (In  my  article  on  Appendicitis  in  the  Berliner 
Minische  Wochensclirift,  1896,  No.  37, 1  described  a  very 
interesting  case  of  this  sort.) 

After  the  inflammation  has  given  up  its  circum- 
scribed character  then  matters  are  much  worse.  Still, 
even  in  such  desperate  cases,  results  are  obtained  now 
and  then,  especially  if  one  has  the  luck  to  discover  en- 
cysted foci  after  external  inspection  and  palpation  of  the 
peritoneal  cavity.    By  exercising  a  great  deal  of  patience 


70  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

it  is  often  astonishing  how  foci  are  discovered  which 
were  not  suspected  on  a  superficial  examination.  An- 
aesthesia should  be  employed  in  such  cases.  Such  foci 
must,  of  course,  be  exposed  thoroughly.  The  peritoneal 
cavity  is  washed  with  a  hot  saline  infusion,  the  fibrinous 
flocks  are  wiped  off  carefully,  and  extensive  drainage  is 
effected  by  the  use  of  iodoform  wicks. 

The  thorough  exposure  of  the  suspicious  peritoneal 
region  first  of  all  permits  a  complete  evacuation  of  the 
pus  accumulations  from  the  edges  and  niches  of  the  ab- 
dominal cavity.  Adhesions,  the  results  of  preceding  in- 
flammatory processes,  can  be  loosened  easily,  even 
though  the  thorough  disinfection  of  the  abdominal  cav- 
ity still  remains  a  pious  desire  rather  than  a  surgical  re- 
ality. Still,  by  these  procedures  a  considerable  amount 
of  accumulated  infectious  material  is  got  rid  of,  not  to 
speak  of  the  most  beneficial  lowering  of  the  intra-ab- 
dominal pressure,  and  the  consequent  freeing  of  the  res- 
piration. There  is  a  series  of  authentic  reports,  accord- 
ing to  which  a  cure  was  effected  in  most  desperate  cases, 
to  the  treatment  of  which  the  surgeon  proceeded  without 
a  spark  of  hope,  where,  for  instance,  the  pulse  was  hardly 
perceptible.  Vice  versa,  however,  many  cases  have  ended 
fatally  where  the  prospects  seemed  entirely  favorable. 

If  the  gangrene  has  persisted  for  several  days,  the 
caecum  will  naturally  particijiate,  considerable  loss  of 
substance  then  occurring  sometimes.  If  the  area  thus 
affected  is  not  thoroughly  exposed  and  the  necrotic  tis- 
sue removed,  the  patient  will  surely  succumb.  I  found 
that  the  best  route  from  wliich  such  foci  are  exposed  is 
by  the  lumbar  region,  a  long,  transverse  incision  being 
made  from  the  abdominal  incision  backward,  if  neces- 
sary to  the  outer  margin  of  the  lumbo-dorsalis  muscle. 


IS  APPENDICITIS   A   SURGICAL   DISEASE?  71 

Sometimes  one  is  surprised  at  the  extent  of  the  necrotic 
process  in  this  region,  which  escaped  notice  if  inspected 
from  the  abdominal  opening  only.  The  latter  should  be 
sewed  up  after  all  necrotic  fragments  are  removed  and 
the  wound  cavity  drained  from  the  lumbar  opening.  In 
two  of  my  most  desperate  cases  recovery  took  place, 
although  these  rigorous  procedures  had  to  be  undertaken 
while  the  patients  were  nearly  conscious,  respiration 
having  stopped  shortly  after  the  ansesthetic  had  been  ad- 
ministered. In  both  cases,  one  being  of  five  and  the 
other  of  seven  days'  standing,  pus  had  been  present  in 
the  urine. 

It  is  no  doubt  depressing  for  a  surgeon  to  proceed  to 
heroic  manipulations  under  such  gloomy  circumstances, 
where  he  must  fear  every  moment  that  the  small  vital 
spark  would  become  extinct.  And,  on  the  other  hand, 
he  can  not  forget  that  such  a  patient  has  nothing  to 
lose  and  everything  to  gain,  and  that  under  these  cir- 
cumstances at  all  hazards  this  last  chance  should  be 
offered  to  him.  His  permission  is  easily  obtained,  for 
such  patients  often  suffer  intensely,  and  are  generally 
cognizant  of  the  hopelessness  of  internal  medication. 
Unfortunately,  in  most  cases,  the  valuable  span  of  time, 
which  may  eventually  offer  a  chance  for  recovery,  is  sac- 
rificed to  aimless  deliberation.  , 

In  infection  of  high  virulence  the  prognosis  is  abso- 
lutely bad.  When,  on  incising  the  peritonseum  a  serous 
exudation  of  a  fsecal  odor  pours  forth,  I  always  say 
to  myself :  "  Lasciate  ogni  speranza."  Up  to  date  I 
have  lost  all  my  cases  of  this  kind.  This  form  of  exuda- 
tion seems  to  point  to  an  infection  of  high  virulence. 
Treatment  with  antitoxine  has  also  proved  a  failure  in 
such  cases. 


72  IS   APPENDICITIS   A   SURGICAL   DISEASE? 

Eegarding  the  occlusion  of  the  abdominal  wall,  pri- 
mary union  should  always  be  striven  for  in  simple  in- 
flammatory processes.  Consequently  the  abdominal  wall 
should  be  sewed  up.  In  simple  abscess  formation  the 
wound  cavity  is  packed  with  iodoform  gauze,  and  the 
abdomen  is  kept  open  and  protected  with  a  large  piece 
of  immobilizing  moss  board.  The  dressing  is  changed 
once  in  three  days. 

If  virulent  infection  is  assumed,  the  moist  open- 
wound  treatment  is  substituted  for  the  dry  open  treat- 
ment by  keeping  the  gauze  filling  in  the  wound  cavity 
constantly  moist  with  formalin.  Instead  of  the  moss 
board  and  the  bandaging,  only  a  compress,  saturated 
with  the  formalin  solution,  is  put  over  it.  If  the  pa- 
tients do  well,  a  laxative  is  given  twenty-four  hours  after 
the  operation.  As  an  anaesthetic,  nearly  always  ether 
was  employed.  For  the  last  six  months  Schleich's  mix- 
tures were  tried,  and  while  I  have  to  acknowledge  the 
ease  with  which  some  patients  came  under  and  out  of 
their  influence,  I  have  failed  to  discover  any  material 
advantages  over  the  usual  methods  of  ether  ansesthet- 
ization. 

All  patients  in  whom  the  open-wound  treatment  is 
tried  have  to  wear  an  abdominal  supporter,  which  has 
to  be  well  padded  on  the  right  side. 


Physicians. 


who  desire  to  keep  au  courant  with  the  advances 
of  medicine  and  surgery  should  read 


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